Woodland Veterinary Centrewoodland logo forms

Grange Rd. Midhurst, West Sussex. GU29 9LT


Consent Form

Operation/ procedure.......................................................

 

Animal Details

This will be already filled in by our computer
Animal Name............................Age............................
Species.................................... Remarks....................
Breed...................................... Weight.......................
Description...............................D.O.B.........................
Sex.........................................Insurance...................
Last seen..................................Vetplan Member yes/no

 

Owner Details

This will be already filled in by our computer

Name

......................................

Address


......................................
......................................
......................................
......................................

Tel No. (home)

.....................................

Tel No.(work)

.....................................

Mobile No.

....................................

Email Address

....................................


 Admission Details

To be filled in by the admission Vet/ Nurse:

Admission nurse....................................................................................

Vet who last examined.....................................................Date...............

Time Animal Name last had anything to eat.............................................

Known allergies/Drug reaction: ..............................................................

On any present medication: ...................................................................

When was Advocate Spot-on last applied? ...............................................

Is he/she insured ?(with whom?).............................................................

What is his/her normal diet?....................................................................

Articles left:...........................................................................................

Is he/she Microchipped? .........................................................................

In case of mass removal,do you wish to have histopathology Yes/No

In case of bitch spay, when was end of last season?..................................

Estimate seen and accepted? ..........................................Yes/No

Post operative Sensitivity Control recovery pack (20% discount) Yes/No

Weight in Kg...............       Temperature...............

 

 I hereby give permission for the administration of an anaesthetic to
Animal Name and to the surgical operation(s) detailed on this form,
together with any other procedures which may prove necessary.
During dental procedures, extractions may be carried out.
While every care and attention will be given to Animal Name's well-being,
I understand that all anaesthetic techniques and surgical procedures
involve some risk to the patient.

 

Date:...............
Signature ...............................................(Owner/Authorised Agent) 
(Owner/Agent, I am over 18 years of age)


Vaccination up to date: Yes/ No
If not up to date, I understand that Animal Name is not covered against certain infectious
diseases and accept the risk of Animal Name contracting such diseases whilst
here in the Veterinary Centre.
Date............
Signature..................................................(Owner/Authorised Agent)
(Owner/Agent, I am over 18 years of age)



 

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