Consent For Treatment Form Cheyenne

Owner Name *

First Name Last Name

Pet's Name *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

Pet's Age *

Pet's Gender *

Breed *

Color of Coat *

Email *

example@example.com

I hereby authorize the following: *

Lab Work X-Rays Hospitalization Other

I, the undersigned, certify that I am the owner, or authorized agent for the owner, of the pet described above. I authorize the doctor and assistants to perform the procedure(s) listed above, including administration of pain relief medications, sedatives, and/or anesthetics, as well as any necessary medical, radiological, surgical, nursing, diagnostic, and/or emergency care for the pet. I have been advised as to the nature of the procedures and their potential risks. I also understand that no guarantee of successful treatment can be made and assume full financial responsibility.

I agree to hold Cheyenne West Animal Hospital harmless, in the absence of negligence, from and against any and all liability arising out of the performance of any of the procedure(s) above. I have been informed that Cheyenne West Animal Hospital is not staffed 24 hours a day. I understand that if my pet requires overnight supervision post-surgically, or hospitalization, my pet will be referred to the appropriate emergency hospital.

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