Medical Consent Form

Owner's Name*
First Last
Pet's Name*
Date*
MM slash DD slash YYYY
Pet's Breed*
Sex*
- Male
- Female
Pet's Age*
Owner's Email*
Emergency Phone*
Vaccines Current?*
- Yes
- No
If NOT current on vaccines, which of the following are needed?
- Rabies
- Distemper
- Bordatella
- Lepto
- Lyme
- Heartworm Test
- Wellness Test
- Fecal Test
- Leukemia
- FeLV
- FIV
- Pedicure
- EAG
- Microchip
- Other
What diagnostic testing or other medical care is needed?
- Blood Tests
- Urine Analysis
- Radiographs
- Fluids (-LV or SQ-)
- Medications
- Hospitalization
- Miscellaneous
Was food or water given after 10:00 PM?*
- Yes
- No
Has patient been given aspirin in the last 7-14 days*
- Yes
- No
What medication(s) is your pet on? Prescription and Non-prescription
I am owner and approve
I am the owner of the above patient; I have read and understand this consent form. I hereby give permission to perform the following procedures as indicated above.
I am authorized individual for owner and approve
I am the authorized individual for the owner of the above patient; I have read and understand this consent form. I hereby give permission to perform the following procedures as indicated above.
*I grant Abell Animal Hospital permission to post my pet’s picture, story and medical information on social media
*I grant Abell Animal Hospital permission to send text message updates to my cell phone number (carrier charges may apply)
Please provide cell phone for text messages
*Important*
If my pet has a serious illness or injury, and in the event such illness or injury becomes critical during my absence, I want the doctors and medical team to:*
- Resuscitate my pet
- Do not resuscitate my pet
*
I also authorize Abell Animal Hospital to perform such diagnostic, therapeutic, and surgical procedures that are in their opinion necessary and advisable to maintain my pet’s health. Including, but not limited to the administration of anesthesia, and the services involving pathology and radiology. The nature of such services has been explained to my satisfaction and I accept all procedures to be done to the best of the abilities of the hospital staff. I realize that no guarantee or warranty has ethically or professionally been made regarding the results or cure. I acknowledge that my pet will be discharged only during regular office hours, when doctors, technicians, and receptionists are present. It is understood that the actual cost may exceed the estimated amount. Payments will be completed in full at time of release.
Signature*
Date*
MM slash DD slash YYYY
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Phone
This field is for validation purposes and should be left unchanged.

Medical Consent Form

*Important*

Important