Fill out the form below or print the pdf. Consent to Treat Consent to Treat Date Date Format: MM slash DD slash YYYY Owner's Name* First Last PhoneEmail Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Animal Name:Animal Breed:Animal Age:Animal Sex* Male Female Normal Diet AM: (for horses staying at facility)Normal Diet PM: (for horses staying at facility)Are you providing the feed:YesNoSpecial Instructions:Procedures to be performed:Signature*By signing above, I consent to the performance of the above procedures on the above listed patient. I further consent to the administration of restraint such as anesthesia and administration of drugs and other procedures as may be considered necessary or desirable in the judgment of the admitting veterinarian. I also consent to the taking of any photographs and/or videos in the course of the treatment for the purpose of advancing veterinary medical knowledge. The risks involved in performance of the above procedure(s) have been explained to me in detail and I fully understand them.