Pet Information

Pet's Name *

Contact Information

Owner's Name *

First

Last

Email *

Phone *

Additional Phone

Secondary Contact: *

First

Last

* This person has your authority to consent to medical decisions regarding your pet's surgical care in the event we cannot reach you.

Secondary Contact Phone *

Today's procedure is: (example: lump removal, exam, etc.) *

Additional Services Desired While Patient Is Sedated

Please select any/all that you would like us to provide while your pet is sedated

Please specify where the lumps are located *

Please specify the additional service(s) you'd like provided to your pet *

Authorization

I authorize consent for my pet. The nature and risks of this procedure have been explained to me. I understand some risks always exist with consent, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any questions have been answered to my satisfaction. *

I have read, understand, and authorize

I authorize Chi West Veterinary Rehabilitation and Integrative Health to perform any additional diagnostic, treatment, or surgical procedure(s) deemed necessary for medical complications or otherwise unforseen circumstances. I understand there are rare complications associated with any consent procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures. I fully understand these risks and understand the veterinarian and hospital staff will try to minimize such risks. I will not hold Chi West Veterinary Rehabilitation and Integrative Health , the veterinarian, or any staff member liable for any complications that may arise. *

I have read, understand, and authorize

Payment due upon services rendered. *

I have read, understand, and agree.

I have read and fully understand this consent form *

Yes

Signature of Responsible Party *

Clear Signature

Date *

Consent Form

Consent Form

Pet Information

Contact Information

Additional Services Desired While Patient Is Sedated

Authorization

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