Treatment Release Form

Treatment Release Form
CLIENT INFORMATION
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contacts on Account

Please list contact names that will have permissions on the patient's account. These individuals will be able to make any and all decisions that can impact the health of the patient. They can not be removed off of the file without written consent from other owners listed on the account.
List Any Contact that Should be on the Account?
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

PATIENT INFORMATION
Pet Name*
Pet Species*
Pet Breed*
Pet Colour*
Pet Sex*

MaleFemale
Spayed/Neutered? (Fixed)*

YesNo
Pet's Date of Birth (or approximate age)*
Insurance Company Name (if applicable)
Any Concerns/ Health Issues?

TREATMENT INFORMATION
I, the undersigned, do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above, that I do hereby give the Allin Veterinary Professional Corporation (Pine Grove Veterinary Hospital), its agents, employees and/or representatives full and complete authority to perform the treatment described as:
Treatment to be preformed?*
and to perform any other lifesaving procedure(s) that may be required to maintain the health of the above described pet in the event of an adverse reaction/event, and I do hereby and forever release the Allin Veterinary Professional Corporation, its agents, employees or representatives from any and all liability arising from said treatment on said animal.

IN CASE OF EMERGENCY
Alternative Emergency Contact Information: This individual MUST NOT be on the patient’s file and have informed consent to make medical and financial decisions on behalf of the patient in the event the MAIN CONTACT can not be reached.
Main Contact Name*

First NameLast Name
Main Phone Number*
Please enter a valid phone number.
Additional Contact Number for Main Contact
Please enter a valid phone number.
Alternative Emergency Contact Information: This individual MUST NOT be on the patient’s file and have informed consent to make medical and financial decisions on behalf of the patient in the event the MAIN CONTACT can not be reached.
Phone Number*
Please enter a valid phone number.
Alternative Contact Name (Must be Named on Patient's File)*

First NameLast Name
Emergency Procedure Options

If we are unable to reach you at the given contact number(s) above, we need consent before surgery on how you would like Pine Grove Veterinary Hospital Staff to proceed in the event of a lifesaving situation please select the option that aligns with how you would like our staff to proceed, please read very carefully and ask staff for any clarification necessary:
Resuscitate my Pet - I give Pine Grove Veterinary Hospital staff permission to complete any medically necessary procedures to preserve my pet's health in the event of a lifesaving situation. Furthermore, I agree to pay the additional associated costs, which can begin at $500 and increase depending on the circumstances*

I GIVE PERMISSION to Resuscitate me Pet - complete any procedure deemed medically necessary, starting at $500.I DECLINE to Resuscitate my Pet - I understand that this decision may affect the recovery and future health of my pet.
DNR - Do Not Resuscitate my Pet - I wish Pine Grove Veterinary Hospital to only perform the agreed-upon procedure. In the event of an emergency, I do not want any other veterinary medical care given to my pet without my permission, even if it to preserve my pet's health or in the event of a lifesaving situation. I understand that this may mean another anesthetic and/or surgical procedure could be required later. I also understand that this decision may affect the recovery of life and future health of my pet.*

I GIVE PERMISSION FOR - DNR - Do Not Resuscitate my Pet Status - only preform the agreed upon procedure.I DECLINE a DNR - Do Not Resuscitate my Pet Status - I want ANY procedure deemed medically necessary, starting at $500.

CONSENT and SIGNATURES
By signing I acknowledge that I have read, understand and filled out all information on this Pre-Surgical Form to the best of my knowledge and give full consent for Pine Grove Veterinary Hospital to proceed with the procedure outlined on this form.
Signature*

Clear
Date*

MonthDayYear
Date
By submitting this form, I agree to the Privacy Policy and consent to the processing of my personal data as described therein.
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Treatment Release Form

CLIENT INFORMATION

Contacts on Account

PATIENT INFORMATION

TREATMENT INFORMATION

IN CASE OF EMERGENCY

Emergency Procedure Options

CONSENT and SIGNATURES