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    ARCACIA Treatment Consent Form

    Uploaded by

    Emma Hosogoe
    This treatment consent form collects information about the client, their pet, and medical history. It details proposed procedures, risks of anesthesia, estimates costs, and payment policies. The client consents to the proposed procedures and agrees to settle any balances.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    ARCACIA Treatment Consent Form

    Uploaded by

    Emma Hosogoe
    27 views3 pages
    This treatment consent form collects information about the client, their pet, and medical history. It details proposed procedures, risks of anesthesia, estimates costs, and payment policies. The client consents to the proposed procedures and agrees to settle any balances.

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

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    This treatment consent form collects information about the client, their pet, and medical history. It details proposed procedures, risks of anesthesia, estimates costs, and payment policies. The client consents to the proposed procedures and agrees to settle any balances.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    27 views3 pages

    ARCACIA Treatment Consent Form

    Uploaded by

    Emma Hosogoe
    This treatment consent form collects information about the client, their pet, and medical history. It details proposed procedures, risks of anesthesia, estimates costs, and payment policies. The client consents to the proposed procedures and agrees to settle any balances.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    TREATMENT CONSENT

    FORM
    Client information
    Owner name [Click/tap here to enter text]

    Address [Click/tap here to enter text]

    Email [Click/tap here to enter text]

    Home phone [Enter number] Mobile phone [Enter number]

    Insurance company [Enter text] Policy no. [Enter number]

    Patient information
    Name [Click/tap to enter text]

    Animal ID [Click/tap to enter text] DOB [Click/tap to enter date]

    Species [Click/tap to enter text] Breed [Click/tap to enter text]

    Colour [Click/tap to enter text] Weight [Enter number]

    Sex Female Male De-sexed Yes No

    MEDICAL HISTORY

    History of Treatment

    Known allergies [Click/tap to enter text]

    Prior illnesses or surgery [Click/tap to enter text]

    Current medications [Click/tap to enter text]

    Diet restrictions or supplements [Click/tap to enter text]

    ARCACIA / Treatment Consent Form 1/3


    Created: 12-05-2016 / Updated: 12-02-2024
    Consent declaration
    I am the owner/agent of the pet described above and have the authority to execute this consent. I am over
    18 years of age. I authorise the above-named veterinary facility to perform the treatments/procedures
    described below. I have been informed of the reasons for the treatments/procedures, along with the
    expected outcome and the risks involved.

    PROCEDURES TO BE CARRIED OUT


    I
    [Click/tap to enter text]

    understand that there are certain risks to anaesthesia and that these risks are present in any procedure that
    requires a general or intravenous anaesthetic. If anaesthesia is needed, I consent to its use.

    ESTIMATE PROVIDED
    The cost of this procedure is estimated to be $ [Enter number].

    PAYMENT POLICY
    The client realises that in many cases, it is not possible to determine in advance the exact extent of medical
    or surgical treatment required for an animal. ARCACIA vets will attempt to estimate the cost of the
    treatment to their best ability, but it is understood that the final cost may exceed the estimate, depending
    on the extent of the treatment required. Where the estimate exceeds 10% of the estimate, staff will attempt
    to call you to notify you of the reasons and provide an updated estimate.

    The client agrees to pay the balance of the fees due at the time the bill is presented. If a balance is due and
    the owner is unreachable, the client consents to having the charges paid by his/her credit card.

    I will settle the account by:

    Cash Credit card Direct debit VetPay Other credit arrangement

    CONSENT
    I have read and understood this consent form. I consent to the proposed procedures.

    ARCACIA / Treatment Consent Form 2/3


    Created: 12-05-2016 / Updated: 12-02-2024
    Client name [Click/tap to enter full name] Date [Click/tap to enter date]

    Signature

    ARCACIA / Treatment Consent Form 3/3


    Created: 12-05-2016 / Updated: 12-02-2024

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