Consent Form For Diagnostics, Treatment, or Surgery

Consent Form For Diagnostics, Treatment or Surgery

Wilmot Veterinary Clinic Prof. Corp. 1465 Trussler Rd, Kitchener, ON,N2R 1S7

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I, the undersigned, an adult major, hereby authorize the veterinarians and staff of this veterinary facility to perform any reasonable treatment/anesthesia & surgery they may deem necessary, including further or alternative measures as may be necessary during the course of the surgery &/or treatment of my animal.

I have read and understand

I'm aware that this veterinary facility doesn't provide 24- hour per day monitoring of patients. Should I wish to have my animal monitored 24 hours per day while hospitalized, I will make arrangements with the staff of this facility.

I have read and understand

I, undertake to keep in daily contact to enable the staff to inform me of the progress, costs incurred, and additional treatment involved, of my hospitalized animal. I may withdraw my consent at any time for any treatment or procedure.

I have read and understand

I recognize that there is some degree of risk attached to any medical or surgical procedure or treatment. I have discussed any concerns I may have with the veterinarian. I hereby absolve the veterinarians, staff and this facility from all actions, arising directly or indirectly from the treatment/anesthetic/surgery.

I have read and understand

I herby acknowledge that Dr. Lofsky, or his/her representative, has advised me of and explained the following proceedureor tenative or final diagnosis of my animal listed below, the general nature of the following procedure or tentative or final diagnosis of my animal listed below, the general nature of the following proposed treatment or proceedure with the expected benefits, risks, dangers, side effects and consequences if the treatment/procedure is not performed.

I have read and understand

In the event that the animal referred to above is not claimed by the person giving this consent within ten days of completion of the discussed treatment and convalescence or of any ancillary service provided by the Wilmot Veterinary Clinic, the animal shall be deemed to have been abandoned, and Wilmot Veterinary Clinic shall be entitled to transfer the animal to an animal shelter or to a third party owner.

I have read and understand

I acknowledge that I have read these conditions and hold myself bound thereto. I am the owner and the owner of the animal described below and am authorized to make decisions regarding care. Furthermore, I have had the fees outlined and agree to pay all such fees and charges at the time of discharge.

I have read and understand

Animal Details

Pets Name

Species

Sex

Pet Parents Details

First

Last

Pet Parents Partner Details

First

Last

Address

Address Line 1

City

State / Province / Region

Postal Code

Best Contact Number Today

(000) 000-0000

Alternate Contact Name

First

Last

Alternate Contact Number

(000) 000-0000

Today's Procedure

Has you pet shown any abnormal signs or symptoms. If yes, please fill below.

I hearby agree to all of the above

Clear Signature

Sign With First and Last Name

Date of the Proceedure

519-696-3102

1465 Trussler Rd. Kitchener, ON N2R 1S7

Consent Form For Diagnostics, Treatment or Surgery

Animal Details

Appointment