Boarding Barn Owner/Agent Agreement Owner/Agent AgreementHorse owner name: *Phone *List the best number to contact you in case of an emergencyName of Boarding Barn or Farm: *If there is no facility name, list the name of the person who is boarding your horse(s).Names of all horses you are boarding at this facility: *Consent Statement I consent to the provision of routine or emergency veterinary services by Springhill Equine Veterinary Clinic, P.A. when such services are deemed necessary for the horse. I grant permission to the person or facility listed above to act as my agent for securing veterinary services for my horse(s). I agree to be fully financially responsible for any payments for services incurred at the direction of my agent. I understand this payment is expected at the time of service. I understand that my agent will be held responsible for my incurred debts, should I fail to provide payment.Please type your initials here to acknowledge your consent: Exceptions: My agent does not have my permission to authorize the following procedures: List services that require your permission, if any.If it should become necessary to refer my animal to a referral-level hospital for further treatment I would like the animal to go to: Example: EMCO, UF Vet School, etc.Is your horse covered by insurance? YesNoInsurance information If yes, please list the name, phone number, and policy number of the insurance company.Emergency Expense Authorization: In the event of an emergency, I agree to spend up to the maximum amount listed here to attempt to save the horse. *Consent for Humane Euthanasia If veterinary treatment is unable to save this horse, I give my consent for humane euthanasia to be performed, and I agree to pay the fees for this service.Please type your initials here to acknowledge your consent: Payment InformationCredit Card Number: *Expiration Date *3-digit Security Code * By digitally signing and submitting this form, you are agreeing to be bound by the terms laid out within this form. You also agree to your credit/debit card being run at the time of service, unless payment is made in other form at time of service.Digital Signature *Please type your full name, which acts as your digital signature.Date * Verification that I am not a robotPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
