IN-STRIDE WITH THERAPEUTIC RIDING, INC.
465 Springdale Road
Eighty Four, PA 15330
412.302.5393
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT FORM
Name: 
DOB:
DOB:Address:Phone:
Phone:E-mail:
Physician's Name:Preferred Medical Facility:
Preferred Medical Facility:Health Insurance Company:Policy#:
Policy#:Allergies to medication:
Current medications:
Emergency Contact Numbers:
Name:Relation:Phone:
Relation:Phone:Name:Relation:Phone:
Relation:Phone:In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize In-Stride with Therapeutic Riding, Inc. to:
1.Secure and retain medical treatment and transport if needed.2.Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.Consent Plan
This authorization includes x-rays, surgery, hospitalization, medication and any treatment procedure deemed "life saving" by the physician. This provision will only be invoked id the person(s) above is unable to be reached.
Date:Consent signature:
Consent signature:Client, Parent or Legal Guardiansigned in the presence of center staffNon-Consent Plan
I do not give my consent for emergency medical treatment/aid in the case of illness during the process of receiving services or while being on the property of the agency.
Parent or guardian will remain on site at all times during equine assisted activitiesIn the event emergency treatment/aid is required, I wish the following procedure take place:Date:Consent signature:
Consent signature:Client, Parent or Legal Guardiansigned in the presence of the center staffPlease print this form and bring it to the next lesson you attend.
