Patient Consent Form
Owner Name
*
First Name
Last Name
Pet Name
*
Current Medications
*
Please add when the last dose was given
Primary Complaints
*
Vomiting
Blood in Urine
Diarrhea
Blood in Stools
Itching
Sneezing
Loosing Weight
Lethargic
Coughing
Hair Loss
Limping
Labored Breathing
Ears
Growth/Lump
Drop off (Sedation, Testing, Other)
Please Describe What Is Going On With Your Pet.
Duration of Symptoms
Was your pet fed today?
*
Yes
No
Time of Last Meal?
*
Please list any previous illnesses or surgeries:
Back
Next
Please select one of the following:
*
I authorize treatment for the estimate that was provided.
Please call me with an estimate before performing any procedures. I understand that if I cannot be reached, my pet will receive NO treatments, except in the case of an emergency.
I authorize testing and treatment deemed necessary by the veterinarian and approve charges up to a certain amount (Please enter the amount in the next question)
Amount you authorize for testing/treatment
(only answer if you picked the second option)
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature
*
I agree that by signing the Electronic Signature Acknowledgment and Consent Form, my electronic signature is legally equivalent to a handwritten one, and I consent to be bound by this agreement.
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SUBMIT
SUBMIT
Should be Empty: