Medical Treatment Consent Form printable pdf download

Medical Treatment Consent Form

MEDICAL TREATMENT CONSENT FORM

Fleur Pet Hospital

4524 Fleur Dr

Des Moines IA 50321

Owner: __________________________________________________

If owner is not present, person dropping off patient: _____________________________

Phone Number: ____________________ Alternate Number: ___________________________

Patient: ____________________________________

Primary Complaint(s): Please check the ones that apply:

Vomiting

Diarrhea

Blood in stool

Coughing

Sneezing

Pain

Difficulty Breathing

Lameness or Limping

Not eating

Not drinking

Urinating frequently or in odd places

Blood in urine

Unable to urinate

Weight loss

Itching

Lethargic or depressed

Increased thrist

Check a growth

Ear problem

Eye problem

Other:______________________________________________________________________________________

Specify Complaint(s): (left leg, growth on face, hiding etc..) __________________________________

_____________________________________________________________________________________________________

Duration of the condition (hours, days or weeks) and any current medications that have

been given for the condition: ___________________________________________________________________

______________________________________________________________________________________________________

Any medications given today: ____________________________________________________________________

For anticipated services, please refer to the estimate that has been figured for you. If there

are more services that need to be done, Dr. Williams will be calling to give an update of

your pets’ condition and her recommendations that may go beyond the initial treatment

plan.

Medical Treatment Consent Form