Small Animal Consent to Treat

Date
MM slash DD slash YYYY
Owner's Name*
First Last
Phone
Email
Address
Street Address Address Line 2 City State ZIP Code
Animal Name:
Animal Breed:
Animal Age:
Animal Sex*
- Male
- Female
Is animal currently on medication?
Meds:
Procedures to be performed:
Owners DOB (For medication dispensing):
Month
Day
Year
Signature*
By signing below, 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.
If you were referred to us please let us know who referred you:
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Large Animal Care