Wellness Procedure Consent Form

Today's Date(Required)

Best Contact Number for Today(Required)

Secondary Contact Number

Patient Name(Required)

Age(Required)

If your pet has known allergies please list them below (food, medications, anesthesia, vaccines, etc.).

Please list your pet's current medications and supplements below, their dosages, the frequency you give them, and when they received their last dose. If they are not on any current medications please type in "N/A" or "no medications" below.(Required)

I hereby consent and authorize Lifetime Pet Center of New Richmond to prescribe for, treat, or operate upon my pet (listed above). I have been advised of the risks associated with treatments and/or surgery. It is thoroughly understood that I assume all risks and will take responsibility for payment of services rendered. Please sign your initials in the space below to acknowledge the above.(Required)

The Lifetime Pet Center of New Richmond will use all reasonable precautions against injury, theft, escape, or destruction of the animal(s) listed above, but will not be held responsible in any manner whatsoever on account of the care, treatment, or safekeeping of the animal(s) above described, as long as acceptable standards of veterinary medicine have been followed. Please sign your initials in the space below to acknowledge the above.(Required)

It is also noted that my pet will be vaccinated if medically neccessary or if recommended by the prescribing doctor in order to protect the safety of my pet and the staff handling my pet. Please note that rabies vaccination is required by county law. In addition, if my pet is found to have fleas or other parasites while in the hospital, s/he will be treated accordingly as seen fit by the doctor and staff. Please notify us if your pet has any allergies or drug sensitivities. Please sign your initials in the space below to acknowledge the above.(Required)

By signing below, I confirm that I have read and understand the information above.(Required)

If other, please specify:(Required)

Please provide an email address if you would like an estimate.(Required)

By signing below, you acknowledge that the estimate (if requested) for the procedure is not a guaranteed price for services. Unforeseen circumstances may arise that could increase the cost of the procedure we are performing today. We will make a reasonable effort to inform you and obtain consent for any additional services before proceeding, except in the case of a life-saving emergency. If you have any questions or concerns, please speak with a staff member before your pet's procedure.

Signature(Required)

Provide Your Pet’s Wellness Information

Complete the Wellness Procedure Consent

Contact Us

Contact

Location

Hours

Have a Question?