VETERINARY TREATMENT CONSENT FORM

DOCUMENT INFORMATION

PRACTICE INFORMATION

[VETERINARY PRACTICE NAME]
- Address: [ADDRESS]
- Phone: [PHONE]
- Emergency Phone: [EMERGENCY PHONE]
- Fax: [FAX]
- Email: [EMAIL]
- License Number: [FACILITY LICENSE]

SECTION 1: CLIENT AND PATIENT INFORMATION

1.1 Client (Pet Owner) Information

1.2 Patient Information

1.3 Insurance Information

☐ No pet insurance

☐ Pet insurance on file:
- Company: [INSURANCE COMPANY]
- Policy Number: [POLICY NUMBER]
- Phone: [PHONE]

SECTION 2: REASON FOR VISIT

2.1 Chief Complaint / Presenting Problem

[DESCRIBE REASON FOR TODAY'S VISIT]

2.2 Duration of Problem

☐ Today/Acute
☐ [NUMBER] days
☐ [NUMBER] weeks
☐ Chronic/Ongoing

2.3 Visit Type

☐ Wellness/Annual Exam
☐ Illness/Sick Visit
☐ Injury
☐ Follow-up
☐ Emergency
☐ Second Opinion
☐ Vaccination Only
☐ Other: [SPECIFY]

SECTION 3: MEDICAL HISTORY

3.1 Vaccination History

☐ Vaccination records on file
☐ Records provided today
☐ Unknown/No records available

3.2 Current Medications

☐ No current medications

3.3 Known Allergies

☐ No known allergies
☐ Known allergies: [LIST ALLERGIES AND REACTIONS]

3.4 Previous Medical Conditions / Surgeries

[LIST RELEVANT MEDICAL HISTORY]

3.5 Diet

• Food Type/Brand: [FOOD]
• Amount/Frequency: [AMOUNT AND FREQUENCY]
• Treats: [TREATS]

SECTION 4: EXAMINATION AND DIAGNOSTIC CONSENT

4.1 Physical Examination

☐ I authorize [VETERINARY PRACTICE NAME] to perform a physical examination of my pet.

4.2 Diagnostic Testing Authorization

I authorize the following diagnostic procedures as recommended by the veterinarian:

Routine Diagnostics:
☐ Blood work (CBC, Chemistry) - Estimated cost: $[AMOUNT]
☐ Urinalysis - Estimated cost: $[AMOUNT]
☐ Fecal examination - Estimated cost: $[AMOUNT]
☐ Heartworm/Tick-borne disease test - Estimated cost: $[AMOUNT]
☐ FeLV/FIV test (cats) - Estimated cost: $[AMOUNT]

Imaging:
☐ X-rays (radiographs) - Estimated cost: $[AMOUNT]
☐ Ultrasound - Estimated cost: $[AMOUNT]
☐ CT scan - Estimated cost: $[AMOUNT]
☐ MRI - Estimated cost: $[AMOUNT]

Additional Diagnostics:
☐ Biopsy/Cytology - Estimated cost: $[AMOUNT]
☐ Culture and sensitivity - Estimated cost: $[AMOUNT]
☐ Electrocardiogram (ECG) - Estimated cost: $[AMOUNT]
☐ Blood pressure measurement - Estimated cost: $[AMOUNT]
☐ Other: [SPECIFY] - Estimated cost: $[AMOUNT]

4.3 Pre-Authorization for Additional Diagnostics

☐ Contact me BEFORE performing any diagnostics not listed above
☐ Pre-authorize additional diagnostics up to $[AMOUNT] if medically necessary
☐ Proceed with any medically necessary diagnostics; I accept financial responsibility

SECTION 5: TREATMENT AUTHORIZATION

5.1 Treatment Consent

I authorize [VETERINARY PRACTICE NAME] and its licensed veterinarians and staff to provide medical treatment for my pet, which may include but is not limited to:

☐ Administration of medications (oral, injectable, topical)
☐ Fluid therapy (IV, subcutaneous)
☐ Wound care and bandaging
☐ Minor procedures under local anesthesia
☐ Pain management
☐ Nutritional support
☐ Hospitalization for observation and treatment
☐ Other treatments as medically indicated

5.2 Specific Treatments Discussed

The following specific treatments have been discussed and recommended:

5.3 Sedation/Anesthesia for Minor Procedures

☐ I authorize sedation or light anesthesia if necessary for diagnostic procedures or minor treatments
☐ I do NOT authorize sedation without additional consent

5.4 Pre-Authorization for Additional Treatment

☐ Contact me BEFORE any treatment not specifically discussed
☐ Pre-authorize additional treatment up to $[AMOUNT] if medically necessary
☐ Proceed with medically necessary treatment; I accept financial responsibility

SECTION 6: INFORMED CONSENT

6.1 Understanding of Treatment

By signing this consent form, I acknowledge that:

☐ The nature of my pet's condition has been explained to me
☐ The proposed diagnostic tests and/or treatments have been explained
☐ The expected benefits of the proposed care have been discussed
☐ The potential risks and complications have been explained
☐ Alternative treatment options, if any, have been discussed
☐ The prognosis (expected outcome) has been discussed
☐ I have had the opportunity to ask questions

6.2 Risks and Complications

I understand that medical treatment involves inherent risks including but not limited to:

☐ Adverse reactions to medications or anesthesia
☐ Infection
☐ Bleeding
☐ Pain or discomfort
☐ Failure of treatment to achieve desired results
☐ Unforeseen complications
☐ Need for additional treatment
☐ In rare cases, death

6.3 No Guarantee

☐ I understand that no guarantee of successful outcome can be made
☐ I understand that medicine is not an exact science and results may vary

6.4 Questions and Concerns

☐ I have been given the opportunity to ask questions
☐ My questions have been answered to my satisfaction
☐ I have had adequate time to consider this consent

SECTION 7: HOSPITALIZATION CONSENT

(Complete if hospitalization is anticipated)

7.1 Hospitalization Authorization

☐ I authorize hospitalization of my pet for:
☐ Observation
☐ Medical treatment
☐ Post-operative recovery
☐ Other: [SPECIFY]

Estimated duration: [DAYS/HOURS]

Estimated daily hospitalization cost: $[AMOUNT]

7.2 Visitation

☐ I understand visitation policies: [POLICY]
☐ I request to be contacted: ☐ Daily ☐ Only if status changes ☐ Other: [SPECIFY]

7.3 Do Not Resuscitate (DNR) Order

In the event my pet experiences cardiac or respiratory arrest during hospitalization:

☐ Attempt full resuscitation (CPR)
☐ Do Not Resuscitate (DNR) - Provide comfort care only

Owner Initials: _______ Date: _______

SECTION 8: EMERGENCY TREATMENT AUTHORIZATION

8.1 After-Hours Emergency

☐ If an emergency occurs after hours, I authorize transfer to [EMERGENCY FACILITY NAME]
☐ Emergency facility contact: [PHONE]

8.2 Emergency Treatment During Hospitalization

If my pet experiences a medical emergency while in your care and I cannot be reached:

☐ Authorize all life-saving treatment regardless of cost
☐ Authorize emergency treatment up to $[AMOUNT]
☐ Provide comfort care only; do not perform extraordinary measures
☐ Contact emergency contact person listed below for authorization

8.3 Emergency Contact

If I cannot be reached:

• Name: [NAME]
• Relationship: [RELATIONSHIP]
• Phone: [PHONE]
• Authorized to make medical decisions: ☐ Yes ☐ No
• Authorized to approve expenses up to: $[AMOUNT]

SECTION 9: FINANCIAL AGREEMENT

9.1 Estimate of Charges

☐ I have received a written estimate of charges
☐ Estimated total: $[LOW ESTIMATE] to $[HIGH ESTIMATE]
☐ I understand the estimate is not a guarantee and actual charges may vary

9.2 Payment Terms

☐ Payment is due at time of service
☐ Deposit of $[AMOUNT] required for hospitalization
☐ Final payment due at discharge

Payment Methods Accepted:
☐ Cash ☐ Check ☐ Credit/Debit Card ☐ CareCredit ☐ Scratchpay ☐ [OTHER]

9.3 Financial Responsibility

☐ I understand I am financially responsible for all services rendered
☐ I agree to pay for all diagnostics, treatments, and hospitalization
☐ I understand that if my pet is not picked up within [NUMBER] days of discharge notification, boarding fees of $[AMOUNT] per day may apply

9.4 Declined Services

I have declined the following recommended services (I understand this may affect my pet's treatment or outcome):

9.5 Cost Limitation

☐ Do not exceed $[AMOUNT] without contacting me first
☐ No spending limit; proceed with medically necessary care

SECTION 10: RELEASE OF INFORMATION

10.1 Medical Records

☐ I authorize release of my pet's medical records to:
☐ Referring veterinarian: [NAME/CLINIC]
☐ Specialist: [NAME/CLINIC]
☐ Other: [NAME/CLINIC]

10.2 Pet Insurance

☐ I authorize release of medical records to my pet insurance company for claims processing

10.3 Photos/Media

☐ I consent to photos/videos for:
☐ Medical record documentation
☐ Educational purposes (staff training)
☐ Social media/marketing (pet will not be identified by name)
☐ All of the above

☐ I do NOT consent to photos/videos beyond medical record documentation

SECTION 11: ADDITIONAL AUTHORIZATIONS

11.1 Medication Dispensing

☐ I authorize dispensing of prescribed medications
☐ I understand instructions for medication administration will be provided
☐ I understand to call with any questions about medications

11.2 Follow-Up Care

☐ I understand the importance of follow-up appointments as recommended
☐ I will schedule follow-up care as directed

11.3 Prescriptions

☐ I request written prescriptions to fill elsewhere: [LIST MEDICATIONS]
☐ I understand I may request prescriptions be filled at this practice or elsewhere

SECTION 12: ACKNOWLEDGMENT AND CONSENT

12.1 Client Acknowledgment

By signing below, I certify that:

☐ I am the legal owner of the pet described herein, or I am the authorized agent of the owner with authority to consent to treatment

☐ I have read and understand this consent form

☐ I have been informed of my pet's condition, the recommended treatment options, associated risks, and prognosis

☐ I have had the opportunity to ask questions and have received satisfactory answers

☐ I authorize [VETERINARY PRACTICE NAME] to perform the examination, diagnostic tests, and treatments described and/or discussed

☐ I accept financial responsibility for all services rendered

☐ I understand that the practice of veterinary medicine involves inherent risks and that no guarantees can be made regarding the outcome of treatment

☐ I have received a copy of this consent form (or will receive one upon request)

12.2 Witness (Optional)

☐ Witness present for consent: [WITNESS NAME]

SIGNATURES

CLIENT (Pet Owner or Authorized Agent):

Signature: _________________________________

Printed Name: _________________________________

Relationship to Pet (if not owner): _________________________________

Date: _________________ Time: _________________

VETERINARY REPRESENTATIVE:

Signature: _________________________________

Printed Name: _________________________________

Title: _________________________________

Date: _________________ Time: _________________

ATTENDING VETERINARIAN:

Signature: _________________________________

Printed Name: _________________________________

License Number: _________________________________

Date: _________________________________

FOR VETERINARY USE ONLY

Clinical Notes

Treatment Administered

Medications Dispensed

Follow-Up Instructions

[DOCUMENT DISCHARGE INSTRUCTIONS]

This Veterinary Treatment Consent Form is provided for informational purposes only and does not constitute legal advice. Veterinary practices must comply with all applicable state veterinary practice acts and regulations. Consult with a qualified attorney and your state veterinary medical board before use.