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Consent to Treat Form

PLEASE REVIEW THIS FORM, INITIAL, & SIGN THE AUTHORIZATION

Pet's Name:*

PT Acct#:

DOB:*

Procedure:*

1. I consent to necessary treatments that the veterinarian recommends. Treatments have been discussed with me and prices can be found on the provided estimate. I understand that as diagnostics are completed, there may be more that may need to be done and added to the invoice based on the results.*

Initials:

2. I consent to have necessary vaccinations updated on my pet if not currently up to date and if they are healthy enough to receive vaccinations. I understand that some pets may develop vaccine reactions, even later in life, and consent to necessary treatment in the occurrence of a reaction.*

Initials:

3. I understand that all reasonable precautions against injury, escape, or death for my pet will be used, but I will not hold Springfield Animal Clinic liable or responsible in any manner in connection therewith, as I assume all risk.*

Initials:

4. I understand that all payment is due at the time of services and I am unable to carry over a balance. No payment plans are accepted. Care Credit can be used, applications are available online if needed.*

Initials:

Consent: I am the owner/agent for the above animal, and I authorize and request the services listed on this form and/or outlined on the estimate. I am aware that there are certain risks and complications associated with anesthesia, surgery, and medications, even with an apparently healthy animal. Complications can occur before, during and/or after any procedure and could range from mild discomfort up to and including death. I authorize the use of appropriate anesthesia and pain medication as needed before, during and after any procedure. I understand that hospital support personnel will be used as deemed necessary by the veterinarian. I further understand that I will be charged for flea medication and a dose will be applied if evidence of fleas is found on my pet today.

Please type your full name in the space below which will serve as your signature on this document.*

Client Signature:
Date:
Phone Number Where I Can Be Reached Today: