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

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 have received an estimate for the procedure. (If you have not, please ask for one now!) 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*

Emergency Phone*

Drop Off Outpatient Release Form

Feeding Information

Authorization

Location

Hours of Operation