Hospital Consent Form

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Hospital Consent Form

Please fill out this form as completely and accurately as possible before your visit.

Name *

First

Last

Date

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Work Phone *

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Color *

l, being responsible for the above-described animal, have authority to grant you my consent to receive, prescribe for, treat and/or operate upon my pet. I understand the surgery or treatment contemplated is: You are to use all reasonable precautions against injury, escape or death of my pet, but you will not be held responsible in any manner in connection therewith as it is understood that I assume all risks. All charges including boarding costs shall be paid upon release from the hospital. If the pet is not called for within days after the time specified for return and the doctor is not notified in writing of an alternate date within the day period, the animal will be considered abandoned and may be disposed of as the doctor sees fit. It is understood that this does not relieve me from paying for all costs of your services and use of your hospital including the cost of boarding, After carefully reading the above, I have signed in agreement.

Signature *

Clear Signature

Hospital Consent Form

Hospital Consent Form

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Powder Ridge Veterinary Hospital

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