Emergency Contact Information Sheet

Emergency Contact Information Sheet

Name of Horse: ______Age: ______

Gender: ______Castrated: ______Breed: ______

Registration Number: ______Microchip Number: ______

Color and identifying markings: ______

Important medical information: ______

Other important information: ______

Horse Owner: ______

If owner is child, guardian for child: ______

Address: ______City, State, Zip: ______

Home Phone #: ______Work Phone #: ______

Cell Phone #: ______E-mail address: ______

In the event of an emergency: (Please Initial each of the following that pertains to you)

______I want to be contacted for all medical emergencies requiring treatment

______I want Triangle H Farm to contact the vet if necessary for treatment

______I will contact or authorize the contact of the vet if necessary for emergency medical treatment

______If I am unreachable, I have appointed a designated decision maker:

Name: ______Contact #: ______

______If there is a medical emergency and I or my designated decision maker is

unreachable, I give Marcy Heepke the authority to authorize emergency

medical treatment including surgery.

______If there is a medical emergency and I or my designated decision maker is

unreachable, I ask that my horse be kept comfortable until I can be

reached to make a decision about surgical procedures and other expensive medical treatment.

______If the situation is grave, and both I and my designated decision maker is

unreachable, I give Marcy Heepke the ultimate say in deciding the life and

death of my horse.

______If the situation is grave and both I and my designated decision maker is

unreachable, I want my horse kept as comfortable as possible until I can be contacted regarding a life and death choice

Horse Insurance Information

Name of Insurer: ______

Insurer Phone #: ______Other #: ______

Policy #: ______

Last update to policy: ______

Policy includes (please check the following)

_____Deductible ______

_____Emergency Medical care up to ______dollars

_____Emergency Colic Surgery up to ______dollars

_____Equine Mortality insurance (if you have this, an autopsy is required)

_____Other: ______

Triangle H Farm will make all attempts to contact the horse owner per this contract, however, if the health of the horse and safety of the other horses or employees are compromised, then Triangle H Farm will fall back on the boarding contract agreement signed by the horse owner. The boarding contract states on Page 3, section G:

Emergency Care: Farm agrees to attempt to contact Owner should Farm feel that medical treatment is needed for said horses, but if Farm is unable to contact Owner within a reasonable amount of time, Farm is then authorized to secure emergency veterinary and / or farrier care required for the health and well-being of said horse. The cost of such care secured shall be paid by owner with 15 days from the day Owner receives notice thereof Farm is authorized as Owner’s agent to arrange direct billing to Owner.

I acknowledge that by signing this emergency contact information sheet, I may be authorizing emergency medical care and the access of my medical insurance for the emergency medical care of my horse and further, quite possibly be authorizing the life and death decisions for my horse to Triangle H Farm.

Signature of horse owner: ______Date: ______