Bergen Veterinary Hospital

1680 TEANECK ROAD
TEANECK, NJ 07666

(201) 837-3470 Fax (201) 353-3400

www.bergenvet.com

Standard Consent Form

Client Name:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Telephone:(Required)

Date:(Required)

Patient Name:(Required)

Species:(Required)

Breed:(Required)

Sex:(Required)

Birth Date or Age:(Required)

I hereby certify that I am the owner of the above-named animal or am responsible for it and have the authority to execute this consent.

I hereby authorize the performance of the following procedure(s):*(Required)

I hereby also authorize the use of such anesthetics as you deem advisable and performance of such surgical or therapeutic procedures as you determine to be indicated.

I agree to indemnify and hold Bergen Veterinary Hospital harmless from and against any and all liability arising out of the performance of any of the procedures referred to above.

I understand that Bergen Veterinary Hospital is not a 24 hour facility.

Print electronic signature of legal owner or responsible person(Required)

AT WHAT NUMBER CAN YOU BE CONTACTED TODAY?(Required)