Healthcare Vet Form

HEALTHCARE VET FORM

Please complete this form in full. The person signing below represents that they are the legal owner or authorized agent for the animal presented for care. Failure to provide accurate information may affect treatment and outcome.

OWNER / CLIENT INFORMATION

PATIENT (ANIMAL) INFORMATION

Pet Name:   Species:   Breed:

VACCINATION & PREVENTATIVE HISTORY

Rabies:   DHPP / FVRCP:   Bordetella:

Heartworm Test Date:   Fecal Test Date:

INSURANCE / PAYMENT INFORMATION

MEDICAL HISTORY

PRESENTING COMPLAINT / REASON FOR VISIT

Date symptoms began:   Has treatment been given prior to visit?

CONSENT FOR DIAGNOSIS & TREATMENT

I authorize the attending veterinarian and staff to perform diagnostic and therapeutic procedures deemed necessary for the health of my animal. These procedures may include physical examination, blood work, urinalysis, radiographs, intravenous catheter placement, anesthesia, surgery, and administration of medications.

I acknowledge that no guarantee has been given as to the results of treatment and I accept the risk that adverse reactions or complications may occur, including but not limited to infection, hemorrhage, anesthetic or drug reactions, cardiac or respiratory arrest, and death.

I authorize the following (check all that apply):

Consent to examination and routine diagnostics (blood, urine, imaging).

Consent to anesthesia and analgesia as necessary for procedures.

Consent to perform surgical procedures and ancillary treatments as recommended.

Consent to blood transfusion if necessary for life-saving measures.

EMERGENCY AUTHORIZATION

If an emergency arises that requires immediate intervention and the owner cannot be contacted, do you authorize the veterinarian to proceed with emergency treatment to stabilize the patient?

Yes — Authorize treatment to stabilize and treat emergency condition.    No — Do not treat without contact. I understand this may increase the risk of poor outcome.

ANESTHESIA & SURGICAL RISK DISCLOSURE

I understand that anesthesia and surgery carry inherent risks. I have been advised of these risks and given the opportunity to ask questions. I consent to the use of recommended anesthetic and monitoring protocols. I agree to the administration of approved pre- and post-operative medications as necessary.

PHOTOGRAPHY & RECORD RELEASE

I authorize photographs, digital images, and clinical information of my animal to be used for medical records, case documentation, and professional education. I understand personal identifying information will be kept confidential unless I provide specific authorization below.

I consent to non-identifying images being used for education and case discussion.

FINANCIAL AGREEMENT & AUTHORIZATION TO CHARGE

I understand that I am financially responsible for all charges incurred for services performed on this animal. Payment is due at the time services are rendered unless prior financial arrangements have been made in writing. In the event of nonpayment, I agree to pay collection and legal fees necessary to collect the debt.

I authorize the release of medical information necessary to process insurance claims and I assign payment of insurance benefits to the clinic where permitted. I understand that the clinic may require payment of estimated costs prior to surgery or hospitalization.

I assign insurance benefits to the clinic and request that payment be made directly to the clinic where permitted.

AUTHORIZATION TO RELEASE RECORDS

ACKNOWLEDGMENT & CERTIFICATION

By signing below I certify that I am the owner or authorized agent of the owner of the above animal. I have read and understand the information on this form, have disclosed all known medical facts, and consent to the treatments as indicated. I accept financial responsibility as stated above.

I acknowledge that I have had the opportunity to ask questions regarding the proposed care and that my signature constitutes informed consent to proceed.

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