Medical Consent Form

Medical Consent Form

Authorization for Medical/Surgical Treatment and/or Anesthesia Consent
Patient Information
Owner Name

First Name Last Name
Pet's Name
Age
Date of Birth

Month Day Year
Date
Gender
Weight (lbs)
Email
example@example.com
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Health Insurance (if applicable)
Insurance Policy ID

Medical Data
Name of Procedure or Treatment to be performed:
(ex. Spay/Neuter, Dental, Foreign Body Surgery, Sedated Xrays, etc.)
Does your pet have any known allergies? If yes, then please specify below.
Is your pet currently taking medications? If yes, then please list the medications and the reasons why they are taking them.
Is your pet fully vaccinated and up to date? If no, please list which ones are needed.

Laser Therapy Consent Form
As part of our commitment to quality care, we are pleased to offer laser therapy as a safe & comfortable treatment option for your pet. We feel that laser therapy provides the best possible care for your pet.

The benefits of laser therapy are:

LESS PAIN - Laser therapy has a high beneficial effect on nerve cells which block pain transmitted by these cells to the brain and which decrease nerve sensitivity.

LESS BLEEDING - Laser beams will significantly increase the formation of new capillaries in damaged tissue that speeds up the healing process, closes wounds quickly, and reduces scar tissue.

LESS INFLAMMATION - Laser therapy has an anti-edema effect as it causes vasodilatation, but also because it activates the lymphatic drainage system (drains swollen areas). As a result, there is a reduction in swelling caused by bruising or inflammation from surgery.

Laser therapy can reduce your pet's post-operative recovery time, leading to a quicker return to normal activities.
Yes, I want my pet to have laser therapy and understand the costs listed below are in addition to normal surgery costs. Please choose the level for your pet coinciding with the surgical procedure he or she may be having.

LEVEL 1 - $55 (spays, neuters, minor skin lesions such as warts, etc.) LEVEL 2 - $65 (oral surgery, eyelid repair, etc) LEVEL 3 - $160 (dermatitis, arthritic sessions, etc.)
No, I decline laser therapy for me pet

Decline
Should be Empty:

Patient Information