Treatment Consent Form

Name of Pet Owner *

First Name Last Name

Phone number where you can be reached today *

Area Code Phone Number

Email *

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Name of Pet *

When providing medical history, please provide sufficient information for each symptom including: when did you first notice it, is it getting better, worse, or staying the same, frequency, appearance, have any treatments been used to treat the problem, any response to treatments, any possible toxin exposure, could pet have ingested anything that may be contributing to symptoms....

Main concern(s) *

Is your pet experiencing any of the following:

Please provide details for any symptoms selected above.

Any medications that the pet is currently receiving? *

Please list dosage, frequency, last received

Does your pet have access to the outdoors (fenced in yard, free range, dog parks etc.)

Does your pet have a history of allergies or adverse reactions to any medications, vaccines etc.? *

When was your pet last treated with a flea/tick medication or heartworm preventative

Please provide product name(s), if known

I authorize sedation of my pet if necessary to perform any treatments or diagnostic tests *

Yes No I would like a call first (please note this may cause a delay and possible rescheduling may be necessary)

I authorize the veterinarian to perform any diagnostic tests deemed necessary: *

Yes No I would like a call to discuss first (please note this may cause a delay and possible rescheduling may be necessary)

Anything else you would like us to know?

FINANCIAL POLICY: Our office accepts Visa, Mastercard, Discover, and American Express. We also accept cash and checks (only with verification of valid drivers license or other ID at time of payment). In addition, we also offer third party financing options for our clients via Care Credit and Scratchpay. Care Credit requires that payment only be made for services as they are rendered, we cannot charge services to your account in advance. Additionally, use of Care Credit requires that the card be present every time and that two forms of identification are verified. We appreciate your understanding of our desire to protect your account/identity. As financing options are offered, we cannot offer additional in-house payment plans for our services. Clients needing additional financial support are encouraged to apply for Care Credit with a co-signer. Full payment is due at the time of service. This includes any charges/fees agreed to by my authorized proxy. Our team is happy to provide any client with a written treatment plan prior to services being rendered. Client will be responsible for a 2% monthly finance charge on accounts over 30 days and any collection and/or legal fees on accounts over 90 days. Your signature below indicates your agreement with these policies.

TREATMENT CONSENT: By signing this document, I declare I am the lawful owner (duly authorized agent for the owner) of pet described above and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of Madison Animal Hospital to examine, diagnose, and/or treat my pet to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I do hereby and by the presents forever release Madison Animal Hospital, its veterinarians, agents, servants, or representatives from any and all liability arising from said treatment(s) on said animal. I have been informed that Madison Animal Hospital DOES NOT PROVIDE 24 HOUR CONTINUOUS MONITORING and I have been offered referral to an emergency hospital that provides this service if recommended.

Signature *

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