Consent to Treat

New Client Registration

Client Treatment Authorization

Client Information

Client Name:

Select an Address

Phone

Patient Information

Patient Name

Patient Breed

Patient Age/DOB

Select an option

Male Castrate

Male

Female

Authorized Agents

In the event you are not able to be present for your appointment, please list any persons authorized by the owner to approve care for the patient and a dollar amount up to which care may be authorized for.

Authorized Individual

Phone

Relationship to Owner/Patient:

Dollar Amount Care is Authorized For:

In the event of an emergency where the owner is unreachable, is the above listed individual authorized to make life or death decisions regarding the patient?

Yes

I acknolwedge that I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent.

I have been informed that there are certain risks and complications associated with any operation or veterinary procedure. They have been explained to me as well. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures. I authorize the use of appropriate sedation and pain relief medication as needed before or after the procedure. I have been informed that there are risks associated with the use of any medication.

I understand the veterinary support staff will be used as deemed necessary by the veterinarian.

Financial Responsibility

I acknowledge legal ownership of and financial responsibility for the above listed patient. I acknowledge that as the owner of the above listed patient I am responsible any costs incurred in the course of treatment and that payment is due at the time of service. Finance charges will be applied to balances outstanding greater than 30 days.

Your Signature

I accept terms & conditions

Thank you for submitting!