Consent Form

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Consent Form

Client Information

Name *

First

Last

Phone *

Patient Information

Patient Name *

Species *

Breed

Weight

When they are being seen? *

I understand that a current rabies and distemper (and Bordetella for dogs) are required upon admission into Courtyard Animal Hospital. *

I understand

I also understand that a current (within a calendar year) heartworm test and stool check for intestinal parasites must also be up to date. *

I understand

Is the pet up to date on required vaccines and annual exam? *

I understand that in the event fleas are noted on my pet, Courtyard Animal Hospital will treat with appropriate parasite control medication while my pet is in the hospital, and I will be charged for the medication. *

I understand

Today's contact number for when pet is ready for pick-up *

EMERGENCIES: If the need for emergency care arises, I give my permission for such care to be administered as deemed necessary by the on-duty veterinarian at Courtyard Animal Hospital. *

I DO give permission
I DO NOT give permission

Date *

Signature *

Clear Signature

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Consent Form

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Location

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