PROCEDURE-CONSENT-FORM-20161

OWNER'S NAME*
DATE*

MonthDayYear
Date
Email*
example@example.com
ANIMAL'S NAME*
SPECIES*
SEX*
AGE*
COLOR*
A veterinarian will examine your pet and perform the procedures you authorize below. Once we have determined what additional treatments or procedures are indicated, we will call you to discuss our findings and to get permission to perform additional laboratory tests or treatments. We will also give you an estimate of costs, if you desire. Please be sure that we have a phone number where you may be reached while your pet is here.
PHONE:*
Procedure Release

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

I authorize the performance of the following procedures:
Procedures*
I authorize the performance of such therapeutic procedures as you determine to be indicated. The nature and risks associated with such procedure(s) have been explained to me and no guarantee has been made as to the results.

I agree to indemnify and hold Golden Valley and Greenbrier Animal Hospitals harmless from and against any and all liability arising out of any of the procedures referred to above. I grant Golden Valley and Greenbrier Animal Hospitals permission to post my pet's picture, story and medical information on social media.

NOTICE-THIS ANIMAL HOSPITAL DISPOSES OF ABANDONED ANIMALS IN ACCORDANCE WITH MINNESOTA STATUTES 346.37, SUBD. 1. BY SIGNING THIS DOCUMENT YOU ACKNOWLEDGE HAVING RECEIVED A COPY THEREOF ON THE DATE INDICATED.
Signature*

Clear
Social Media Opt-Out

I do not want my pet's picture, story or medical information posted on social media
Please check additional services you would like performed while your pet is here. Let us know if you need an estimate of the cost:

Implant microchip for identificationTrim nailsExpress anal glands/bathe areaClear earsOther
Should be Empty: