Claremont Veterinary Hospital

Treatment Consent Form

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Claremont Veterinary Hospital Treatment Consent Form

Please fill out the form below as accurately as possible!

Name *

First

Last

Email *

Primary Phone *

That can be reached at today

Secondary Phone

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Sex *

Male
Neutered Male
Female
Spayed Female

I, the undersigned owner, agent of the owner of, or Good Samaritan responsible for seeking veterinary care for the pet identified above, certify that I am the age mentioned below. I consent to the examination of this pet by staff veterinarians at Claremont Veterinary Hospital. I also agree that after consultation with me, the hospital’s doctors may prescribe medication for, treat, hospitalize, sedate, anesthetize and/or perform surgery on my pet. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated. Should unexpected life-saving emergency care be required and the attending veterinarian is unable to reach me, the hospital staff has my permission to provide such treatment, and I agree to pay for such care.I understand that an estimate of the fees for veterinary services will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered and during my pet’s ongoing medical treatment. If this petis hospitalized, I agree to pay a deposit of 50% of the estimated fees. I agree to assume financial responsibility for the remaining fees and will provide payment via cash or credit card the time my pet is discharged from the hospital. In the event the pet is hospitalized for more than 48 hours and the attending doctor is unable to reach me, I understand it is my responsibility to call the hospital at least every 48 hours to inquire as to the medical status of my pet and the fees incurred for medical services up to that day. I agreeto pay a monthly billing and financing fee equal to 1.5% of any unpaid balance. I understand that veterinary care during nighttime hours and/or weekends is provided at the discretion of the attending veterinarian. Continuous presence of personnel may not be provided during these hours. I agree that either I, or an authorized agent of mine, will pick up this pet and pay for all accrued charges within ten days of receiving written or oral notification that this pet is ready tobe released from the hospital. Such notice will be given at the address maintained on the hospital’s patient/client record. I agree that if I fail to comply with this policy, the hospital may handle this abandonment in a manner that is in the best interests of the pet and the hospital. *

I have read and accept the financial policy.

Please check one:

I, the owner am above the age of 18.
I, the owner am under the age of 18

PLEASE NOTE: ANY PET ADMITTED WITH EVIDENCE OF EXTERNAL PARASITES (FLEAS, TICKS, ETC.) WILL BE TREATED AT THE OWNERS EXPENSE. VETERINARY SERVICE DURING NIGHTTIME HOURS, SOME DAYTIME HOURS AND/OR WEEKENDS IS PROVIDED AT THE DISCRETION OF THE VETERINARIAN IN CHARGE. CONTINUOUS PRESCENCE OF PERSONNEL MAY NOT BE PROVIDED DURING THES HOURS.

Signature *

Date / Time

Comment

Treatment Consent Form

Claremont Veterinary Hospital Treatment Consent Form

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