Healthcare Veterinary Care Layout

VETERINARY CARE - PATIENT INTAKE AND CONSENT

Owner / Client Information

Patient (Pet) Information

Emergency Contact

Insurance Information (If Applicable)

Medical History

Presenting Complaint / Current Condition

Authorizations, Consent & Financial Responsibility

I, the undersigned owner or authorized agent, hereby authorize the attending veterinarian and clinic staff to examine, diagnose, prescribe for, and treat the animal described above. I consent to the performance of diagnostic procedures, medical treatment, anesthesia, surgical procedures, and administration of medications as deemed necessary by the attending veterinarian. I understand that all medical procedures and anesthesia carry inherent risks and that no guarantees are made as to outcome.

I acknowledge financial responsibility for all charges incurred in the care of this patient and agree to pay all fees at the time of release unless prior written arrangements are made. I understand that estimates provided are not guarantees and additional charges may be incurred for complications or unforeseen findings. The clinic may retain possession of patient records until account balances are satisfied.

In the event of an emergency or if immediate treatment is necessary and reasonable attempts to contact me are unsuccessful, I authorize the clinic to provide emergency medical or surgical treatment at the discretion of the attending veterinarian. I understand the clinic will make reasonable efforts to contact the emergency contact listed above.

I authorize release of medical records, diagnostic reports, and radiographs to referring veterinarians and to the policyholder or insurer as necessary to process claims. I grant permission for clinical photographs or video of my animal for the purposes of diagnosis, treatment documentation, and clinic records. I understand photographs may also be used for educational purposes without identifying client information.

Acknowledgment and Certification

By signing below I certify that I am the owner or authorized agent of the owner of the patient named in this form. I have read and understand the foregoing authorizations, consents, and financial terms. I have disclosed all known medical history and behavioral concerns to the best of my knowledge. I hereby release the clinic and its veterinarians and staff from liability for actions taken in good faith under this authorization, except in cases of gross negligence or willful misconduct.

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