400046 - Confederate Woods Veterinary Hospital

Today's Date*

MonthDayYear

Account Number

Client Name*

First NameLast Name

Email*

example@example.com

Primary Phone Number*

Please enter a valid phone number.

Primary Phone Type*

Alternate Phone Number

Please enter a valid phone number.

Alternate Phone Type

Preferred Method of Contact*

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pet's Name*

Pet's Species*

CatDogExotic

Pet's Breed

Pet's Color/Coat

Pet's Age/Birthday*

Pet's Sex*

MaleFemale

Neutered/Spayed?*

YesNo

Other:

Surgery or Treatment Contemplated

I, being responsible for the above-described animal (the pet), grant you my consent to receive, prescribe for, treat and/or operate upon the pet. I understand that the surgery or treatment is contemplated as described above.

You are to use all reasonable precautions against injury, escape, or demise of the pet, but you will not be held liable or responsible in any manner whatever or under any circumstances on account of the care, treatment, or safekeeping of the pet or otherwise in connection therewith, as it is thoroughly understood that I assume all risks.

I also understand that conditions not known may make it advisable that other surgery or treatment be conducted and I authorize such other surgery, treatment, and pain medication when and if they are deemed advisable. I consent to the administration of such anesthesia and pain medication as may be deemed proper by the doctor.

I acknowledge that no assurance or guarantee has been made of the results of surgery or treatment and that the risks and probabilities of complications exist in any surgical or medical treatment. If the pet is not called for within ten (10) days after the time specified for return, and if the doctor is not notified in writing of an alternate date within the ten-day period, the pet will be considered abandoned. I understand that abandoning does not relieve me from paying all costs of your services and use of your hospital including the cost of boarding. I understand that all charges including boarding costs shall be paid when the pet is released from the hospital.

I understand that 24-hour care is not provided. If continuous care is deemed appropriate for my pet, the doctor may recommend a transfer to an overnight or 24-hour facility.

Do you consent to the application of a flea treatment if there is evidence of a flea infestation found on my pet during the physical exam?*

Yes, I consentNo, I do not consent

Do you consent to having pictures and/or updates about your pet(s) posted on Confederate Woods Veterinary Hospital’s Social Media accounts and website?*

Yes, I consentNo, I do not consent

After carefully reading the above, I have signed in agreement.

Printed Name for E-Signature*

First NameLast Name

Date *

MonthDayYear

Are You A Robot?*

Terms & Consent