Owner Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) Horse Name(Required) Breed(Required) Sex(Required) Age(Required) I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age. I have been informed that there are certain risks and complications associated with live cover. I understand that this can be dangerous and although MVEH will try everything possible to avoid injury my mare could be injured. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian(ie, Sedation,use of hobbles, etc.). I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated. I authorize the use of appropriate anesthesia and other medications as needed before, during or after the procedure. I have been informed that there are risks and additional cost associated with the use of any medication.Untitled(Required) I understand that my mare (without foal by her side) can and may be placed in a field with other mares during her stay at the hospital. With introductions into a new herd injury may occur to my mare and I do not hold MVEH liable for those injuries. I understand that my mare has a foal by her side and that she may be placed in a field with other mares and foals during her stay at the hospital. With introductions into a new herd injury may occur to my mare or foal and I do not hold MVEH liable for those injuries. MVEH will restrain and separate the foal while the mare is being live covered as to insure a safer environment. If you would like your mare to be in a stall or a field by herself that can be arranged. Additional cost will be incurred. I understand that I am responsible for all additional cost. My mare will be tagged with some sort of identification( ie, neck collar, name plate on halter, or cattle tag) prior to arrival. If she arrives with no identification MVEH will issue one to be placed on halter. Halter must be leather as to allow for break away in an emergency. Foals by the mares side will also be given identification if not already on on arrival.Identification Type(Required) Identification Name or Number(Required) Date Last Vaccinated(Required) MM slash DD slash YYYY Stallion Name(Required) The nature of these operations or procedures has been explained to me and I understand what will be done. I am aware Page 1 of 2 that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful pregnancy. I have been encouraged and given the opportunity to discuss any questions I may have regarding my mare's medical care and my questions have been answered to my satisfaction. I accept that my financial obligations remain regardless of the outcome. I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment.Signature(Required)Date(Required) MM slash DD slash YYYY
