Patient Consent Form

Patient Info

Name:

Species

Sex:

Age

Breed

Appointment/Referral Info

Date of Appointment

Appointment Type

Pet Owner

Name:

Phone

Email

Host Hospital

RDVM:

I verify that I am the owner (or authorized agent for the owner) of the above-named animal and authorize Sarah Cocker-Scott, DVM DACVIM, of Vet2Vet Internal Medicine, to perform the requested procedure(s). I have been advised as to the nature and potential complications of the requested procedure(s). I also understand that sedation and/or general anesthesia may be required in order to facilitate the procedure(s) requested. I understand that the clinic listed will be in charge of, and responsible for, monitoring my pet while he/she is sedated and /or anesthetized. I understand that there is no guarantee or warranty made as to the outcome or result of the requested procedure(s).

Marketing/Social Media Authorization

Owner Signature

Date