Drop Off Out Patient Consent Form – Veterinarians Cedar Rapids, IA

Drop Off Outpatient Release Form

Owner*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Patient*
First
Breed*
Color*
Reason for being seen today:*
How is your pet doing today?*
Medications
Medication Name
Last Time Given - Please indicate AM or PM
Feeding Information
Diet Fed*
Approximately how much do you feed your pet per day*
Approximately when is the last time your pet has ate any food or treats*
Please indicate any food allergies:
Authorization
Should any unforeseen procedures be necessary and indicated in the veterinarian’s professional judgment, please select one of the following options:
- I prefer that you proceed with all necessary procedures.
- I prefer to be called before any additional procedures. If I cannot be reached, I DO authorize you to proceed with any procedures as deemed necessary by the doctor.
- If I cannot be reached by phone, I DO NOT authorize you to proceed with any additional procedures. I am satisfied after speaking with the staff of Frey Pet Hospital that they will treat as they deem necessary for his/her health, safety, and well-being; however I do understand that no guarantee of successful treatment can be made. I acknowledge that I have read and fully understand this Authorization for Medical Treatment, the reason why such medical treatment is considered necessary, as well as, its advantages and possible complications, if any. I acknowledge that a small area of hair may be shaved in order to obtain a sample.
The best number I can be reached at:*
Consent*
I understand that payment is due at the time of my pet's discharge and that a deposit may be required for extensive medical or surgical procedures.
Electronic Signature*
- I Agree
By checking this box you agree to the information and terms listed on this form and confirm them to be accurate to the best of your knowledge.
Date*
Date Format: MM slash DD slash YYYY
Emergency Phone*

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Drop Off Outpatient Release Form

Feeding Information

Authorization

Location

Hours of Operation