Vet2Vet Internal Medicine Patient Consent Form

Vet2Vet Internal Medicine Patient Consent Form
Date*

MonthDayYear
Date
Pet Owner's Name*

First NameLast Name
Pet Owner's Email*
example@example.com
Pet Owner's Phone Number*
Please enter a valid phone number.
Patient's Name*
Referring Veterinarian*
Referring Vet Clinic*
I verify that I am the owner (or authorized agent for the owner) of the above-named animal and authorize Sarah Cocker-Scott, DVM, DACVIM, of Vet2Vet Internal Medicine, to perform the requested procedure(s). I have been advised as to the nature and potential complications of the requested procedure(s). I also understand that sedation and/or general anesthesia may be required in order to facilitate the procedure(s) requested. I understand that the clinic listed will be in charge of, and responsible for, monitoring my pet while he/she is sedated and/or anesthetized. I understand that there is no guarantee or warranty made as to the outcome or result of the requested procedure(s).
Marketing/Social Media Authorization*

I authorize images of my pet to be obtained and used at the discretion of Vet2Vet Internal Medicine for lectures, publications, marketing and social media.I DO NOT authorize images of my pet to be obtained and used at the discretion of Vet2Vet Internal Medicine for lectures, publications, marketing and social media.
Owner Signature*

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