Medical History & Consent to Treat

Medical History & Consent to Treat

Please tell us why we are seeing your animal today & agree to treat them
Your Full Name*

First NameLast Name
Contact Number*
Email Address*
example@example.com
Your Animal's Name*
Pet/Equine Insurance Policy and Number if applicable
Primary reason/concern for your visit today*
Check the symptoms that your animal is currently experiencing:*

Appetite LossBleedingCoughingLimping/LameGaggingIncreased ThirstBreathing ProblemsLoss of BalanceSneezingScratchingWeight gainWeight lossBehavioral ChangeVomitingDepressionHead shakingScootingDepressionWeaknessEye injuryVision ProblemsDiarrheaUrination/PeeingBiting selfColicHoof issueSkin IrriationOther
Please check what your horse or livestock animal currently eats and has access to. Please skip if you are bringing a pet in today.

PastureGrass HayAlfalfa HayTeff HayComplete feedWhite Salt BlockRed Salt BlockSelenium BlockClean water trough at all timesCreek WaterIrrigation WaterOther
What supplements do you feed your animal? Please list all of them.*
Check if your animal has ever:

Bit someoneAttacked other animalsLunged at peopleMy animal has never bit anyone
Is your animal taking any medication?*

YesNo
Please list them.
Does your animal have any allergies?

YesNoNot Sure
Please list them.
Please describe the issue you have been seeing and share any additional history*
Consent to Treat

I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent.
I hereby consent and authorize Dr. Keaton Massie, Massie Mobile Veterinary Services, LLC., to perform the following examinations, procedures or operations

The nature of these operations or procedures has been explained to me, and I understand what will be done.

I have also been informed that there are certain risks and complications associated with any operation or procedure of this type. They have been explained to me as well. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures.

I authorize the use of appropriate anesthesia and pain relief medication as needed before or after the procedure. I have been informed that there are risks associated with the use of any medication.

I understand that hospital support personnel will be used as deemed necessary by the veterinarian.
Signature*

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