Treatment Consent Form
Patient Name
(Required)
First
Last
I hereby give Symbios Animal Health - Chatham, and any of it's doctors, authorized agents, staff, or representatives consent and authority to perform the procedures or operations discussed in the treatment plan provided.
(Required)
Yes
No
The nature of the operation(s) or procedure(s) have been explained to me, and I understand what will be done.
(Required)
Yes
No
I have also been informed that there are certain risks and complications associated with any operation or procedure of this type. They have been explained to me as well. I further understand that during the course of the operations or procedures, unforeseen conditions may arise the may necessitate the performance of additional procedures.
(Required)
Yes
No
I authorize the use of appropriate anesthesia and pain relief medication as needed before or after the procedure. I have been informed that there are risks associated with the use of any medication.
(Required)
Yes
No
I understand that hospital support personnel will be used as deemed necessary by the veterinarian.
(Required)
Yes
No
If your pet needs to stay overnight at our hospital please be aware that this facility does NOT provide supervision for animals after normal business hours by a person physically on the premises.
(Required)
Yes
No
Has food been withheld since 10 p.m. the evening before?
(Required)
Yes
No
Is the Patient currently on any medications?
(Required)
Yes
No
What medications and dosages?
Conset
(Required)
I have read and understand the procedures outlined in this authorization and the below name will serve as an E-Signature and consent.
Name
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
Primary Contact Number
(Required)
Secondary Contact Number
(Required)
Email
(Required)
Signature
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