Standard Consent Form

Owner

Pet's Name

I am the owner of the above named animal or am responsible for it and have authority to execute this consent. I am over eighteen years of age.I authorize the performance of the following procedure(s):

I hereby consent to the hospitalization of the above-named animal and authorize the doctor and staff to administer any medication, tests, or surgical procedures that the doctor deems advisable for the health, safety, or well-being of my pet. I also authorize the use of such anesthetics as you deem advisable in the performance of such surgical, diagnostic or therapeutic procedures. I realize that the administration of any anesthetic agent carries a small but real possibility of side effects which include death. I recognize the nature of the procedure(s) being performed and realize that there are certain risks and complications, which have been explained to me.

I understand that at night there may be times when there will not be anyone here with my pet.

I acknowledge that no guarantee or assurance has been made as to the results that may be obtained.

I agree to indemnify and hold Animal Medical Clinic and its doctors and employees harmless from and against any and all liability arising out of the performance of any of the procedures referred to above.

Would you like to have a microchip placed in your pet?

YesNo

Does your pet require a special diet?

YesNo

If yes, please specify and bring some of the food with your pet

What time did your pet last eat?

Time

AMPM

What medications is your pet taking and when was it last given (Include Over-the-Counter Medications)?

(Please bring any medications with your pet)

Signature

Date

How would you like us to contact you today with updates?

Phone CallEmailText Message

Phone Number

E mail Address

example@example.com

Would you allow us to use your pet's photos on our website or social media?

YesNo