Consent for Patient Treatment

1
Owner Name* This field is required.
First Name
Last Name
2
Patient Name:* This field is required.
3
What is the best phone number to reach you TODAY to discuss your pet's care?* This field is required.
Area Code
Phone Number
4
Email
example@example.com
5
What is the best way for us to contact you today?* This field is required.
Phone
Text
Email
Other
6
We will do our best to accommodate your pick up schedule, please indicate if you need to pick up your pet by a specific time today:* This field is required.
7
Who are we authorized to release your pet to other than you?* This field is required.
8
Are you leaving any items with your pet (leash/collar/etc)? If so, please describe:* This field is required.
9
I am the owner or agent for the above named animal and have the authority to execute this consent. I hereby consent and authorize the following as needed for the veterinarian to diagnose and treat the above named animal:* This field is required.
Physical Examination
Flea/Tick Treatment (required at your expense if your pet is found to have fleas or ticks)
Sedation or Anesthesia
Radiographs
Laboratory Testing / Bloodwork / Urinalysis
Vaccinations
Medications
Ultrasound
Hospitalization
All of the Above
Other
10
If requesting Vaccinations, please indicate your pet's needs:* This field is required.
Rabies
DHLPP (Distemper/Parvo/Lepto/Parainfluenza) - dog only
Bordetella (Kennel Cough) - dog only
Feline Leukemia and FVRCP (Calici/Rhinotracheitis/Chlamydia) - cat only
No Vaccines Needed - All Up to Date
Sick Patient - Administer Vaccines if Approved by Doctor
11
Do you have any additional notes on your pet's condition or any additional requests?
Huge
Large
Normal
Small
Ok
Ok
12
Please indicate how would like the doctor to proceed:* This field is required.
Do nothing beyond basic physical examination until I can authorize treatment based on an estimate
Do what he feels is medically necessary to treat and diagnose my animal without regard to cost
Do what he feels is medically necessary to treat and diagnose my animal not to exceed the dollar amount listed below:
Other
13
Authorization for Services Based on Estimate:* This field is required.
I have not yet received an estimated cost for recommended treatment
I have received an estimate and approve the treatment plan as discussed with the doctor not to exceed the dollar amount listed below:
Other
14
If your pet is found to have fleas or ticks, a parasite preventative product will be applied to your animal and you will be charged the full cost of this product. Do you understand?* This field is required.
YESNO
15
I, the undersigned owner or authorized agent of the above patient, hereby authorize the Doctors of the Animal Clinic of West Plains, Inc. to administer necessary treatment and perform medical procedures. In signing below I am indicating that I understand fully the risks involved in performance of the above described procedures. I further understand that no guarantee of successful therapeutic or diagnostic outcome is made. I also assume financial responsibility for all charges incurred, and agree to pay all charges at the time of release, unless other arrangements have been made PRIOR to admission to the Clinic and PRIOR to treatment of the above described animal. Payment is accepted by cash, check, credit card, or CareCredit. We are not responsible for any acts of God that may occur while your pet is staying with us.
16
Signature of Owner/Agent* This field is required.
Clear
17
Date
Date
Month
Day
Year
Should be Empty: