Standard Consent Form

Bergen Veterinary Hospital

1680 TEANECK ROAD

TEANECK, NJ 07666

(201) 837-3470 Fax (201) 353-3400

www.bergenvet.com

Standard Consent Form

Client Name:*

Address:*

Telephone:*

Date:*

Date

Patient Name:*

Species:*

Breed:*

Sex:*

Birth Date or Age:*

I hereby certify that I am the owner of the above-named animal or am responsible for it and have the authority to execute this consent.

I hereby authorize the performance of the following procedure(s):*

I hereby also authorize the use of such anesthetics as you deem advisable and performance of such surgical or therapeutic procedures as you determine to be indicated.

I agree to indemnify and hold Bergen Veterinary Hospital harmless from and against any and all liability arising out of the performance of any of the procedures referred to above

I understand that Bergen Veterinary Hospital is not a 24 hour facility.

Print electronic signature of legal owner or responsible person*

AT WHAT NUMBER CAN YOU BE CONTACTED TODAY?*