Treatment Consent

1642 Hwy 160 West, Suite 104

Fort Mill, SC 29708

(803) 547-8387

www.baxtervet.com

Glucose Curve Form

Client Name *

Patient Name *

Your pet is staying with us for a glucose curve today. We will be taking blood glucose measurements throughout the day to determine if the insulin dose is adequate, or if an adjustment is needed. We also need some basic information on your pet's current regimen.

Diet:

Fed last at what time?

Yes No

Type of insulin:

Dose:

Time last administered:

Has your pet been experiencing any of the following symptoms at home: increased thirst, urination, appetite, weight loss, vomiting, trouble with vision?

Yes/No and details here.

Current Medications:

Refills Needed:

I hereby certify that I am the owner of the above-named animal or am responsible for it and have the authority to execute this consent.

In the event of a life-threatening emergency, I do / do not authorize the Baxter Vet staff to perform CPR on my pet. *

I agree to indemnify and hold Baxter Veterinary Clinic harmless from and against any and all liability arising out of the performance of any of the procedures referred to above.

Electronic Signature *

Best Contact Name and Phone Number: *

You will be notified by text when your pet's glucose curve is complete.