Equine Intake Form | Midwest Veterinary Dental Services

"*" indicates required fields

1Owner’s Information

2Patient’s Information

3Medications

4MVDS Information

5Owner’s Consent

Owner's Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

What is your preferred contact method?*

Patient's Information

Name*

Breed*

Color*

Sex*

Animal's Age*

Approximate date of last Eastern/Western/Tetanus (EWT) vaccination?

Month

Day

Year

Approximate date of last Rabies vaccination?

If not vaccinated within the last 12 months, your horse is at an increased risk for health concerns.

Month

Day

Year

Approximate date of last Flu/Rhino vaccination?

If not vaccinated within the last 6 months, your horse is at an increased risk for health concerns.

Month

Day

Year

Has your horse had any recent bloodwork done?*

Yes

When was the bloodwork performed?

Month

Day

Year

If your horse is over the age of 15 and has not had bloodwork in the previous 30 days, we recommend preoperative bloodwork at MVDS prior to surgery.

Do we have permission to perform bloodwork on your horse today?*

The cost is $165.

Yes

If you have a gelding, would you like his sheath cleaned?*

Yes

Medications

Please list all medications your horse currently is taking:

Do you have antibiotics at home?*

Yes

What type and how much?

Do you have Bute at home?*

Yes

How much?

Does your horse have any health alerts?

Please list things like drug allergies, vices, bad habits, loose stool, etc.

Please provide any special feeding instructions for your horse:

Can your horse eat hay?*

Yes

MVDS Information

Post-Operative MVDS Feeding Protocol

We will be feeding a Purina senior mash and Outlast (gastroprotectant) on surgery day and day after. If you choose to bring your own feed, we ask that you put them in bags with labels on each bag of all contents.

Referring DVM

Clinic name

If extraction(s), would you like to keep the tooth/teeth?*

Yes

Surgery Patients:

No riding/working for 7-10 days or as directed. Rechecks are generally recommended 2-6 weeks following surgery.

Owner's Consent

Consent to treatment*

I hereby certify that I am the Owner or Agent of the Owner of the above-described animal to be treated and/or admitted (“the patient”), that I am over eighteen (18) years of age, and that I have full and complete authority to sign this Consent to Treatment form and to obtain Veterinary services including examination, diagnostics, procedure(s), medication, treatment and/or euthanasia for the animal. I certify that I have read and understand this Consent to Treatment carefully and in its entirety, and that the information provided is true and correct.

The nature of the examination, diagnostics, procedure(s), medication and/or treatment referenced above and the risks involved, including the risks of anesthesia and pain relief medication, of my chosen course of action as well as the other options have been explained to me and I realize that the results cannot and have not been guaranteed and that unfavorable results may occur. I have had an opportunity to discuss all of my concerns as well as the estimated cost of the examination, diagnostics, procedure(s), medication and/or treatment listed above prior to the services being provided.

I understand that MVDS does not guarantee that continuous or twenty-four (24) hour care or supervision will be provided. Support personnel in addition to the Primary Veterinarian and Primary Assistant may be used. I understand that during the performance of my chosen course of action, unforeseen conditions may be occur which necessitate a change in or addition to my chosen course of action and I authorize MVDS to proceed with such changes and additions, including additional examination, diagnostics, procedure(s), medication and/or treatment, which may result in additional costs.

I understand that I will be responsible for payment in full for all services at the time the animal is discharged from MVDS, in accordance with MVDS’ financial policy. I agree that this Treatment and Informed Consent Form may be modified after additional consultation with an MVDS veterinarian and I expressly agree that my oral consent will become part of this Consent to Treatment Form.

I agree to these terms

Image/Media Consent

I grant to Midwest Veterinary Dental Services, its representatives and employees, the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Midwest Veterinary Dental Services may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content.

I agree to these terms

Would you be willing to take our after-visit survey?*

Yes

I hereby give my express consent to Midwest Veterinary Dental Services LLC to perform the following as my chosen course of action as recommended above.*

Please use the mouse or your finger (on touchscreen devices) to sign below.

Owner/Agent Name*

Please print the name of the person who signed above.

First Last

Date signed*

Month

Day

Year

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Owner's Information

Patient's Information

Medications

MVDS Information

Post-Operative MVDS Feeding Protocol

Surgery Patients:

Owner's Consent

Clinic Location

Request an appointment

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Affiliated Organization