Consent for Patient Treatment

Consent for Treatment

Please use this form to authorize consent for procedures for a patient that has already been examined by the veterinarian.
Owner Name *

First Name Last Name
Patient Name: *
What is the best phone number to reach you TODAY to discuss your pet's care? *

Area Code Phone Number
Email *
example@example.com
What is the best way for us to contact you today? *

Phone Text Email
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: *
Who are we authorized to release your pet to other than you? *
Are you leaving any items with your pet (leash/collar/etc)? If so, please describe: *
Consent for Procedure:
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: *

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
If requesting Vaccinations, please indicate your pet's needs: *

Rabies DHLPP (Distemper/Parvo/Lepto/Parainfluenza) - dog only Bordetella (Kennel Cough) - dog only Canine Bivalent Influenza - 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
Please indicate how would like the doctor to proceed: *

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:
Authorization for Services Based on Estimate: *

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:
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 invovled 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.
Signature of Owner/Agent *

Clear
Date

Month Day Year
Date
Should be Empty:

Consent for Treatment

Consent for Procedure: