Hillside VH - Consent Form

Consent Form
Client Name: *

First Name Last Name
Address: *

Street Address

Street Address Line 2

City Province

Postal Code
Phone Number: *
Please enter a valid phone number.
Pet(s): *
I will be absent on the date(s) stated: *
During my absence my pet(s) will be under the care of: *
Caregiver's Name
In an emergency I may be reached at Area Code* Phone Number*. If I am unable to be contacted I have arranged for the caregiver to make any necessary decisions for my pet(s).
I hereby authorize Hillside Veterinary Hospital to perform all procedures as discussed or as deemed necessary by the attending veterinarian, and agree to pay all costs incurred.
Client Signature: *

Clear
Today's Date:

Month Day Year
Date
Should be Empty: