Minor Home Procedures Consent Form for Mobile Vet Services Owner Information Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Pet Information Name * Age * Date of Birth * Estimate if unknown Weight * Indicate if lbs or kg Procedure Information Procedure * Date of Procedure * MM DD YYYY Allergies (if any) Current Medications (if any) When is the last time the pet ate? * MM DD YYYY Time * Hour Minute Second AM PM Consent I do hereby give the Veterinary Home Care Services, and such assistants as may be selected by them, complete authority to perform the above procedure(s), which I understand, or which have been explained to me. If I have not been informed regarding the above procedures to my satisfaction or do not understand, it is my responsibility to inquire at the time of signing this document. I understand that unforeseen conditions may be revealed during the identified procedure(s) which, in the opinion of the attending veterinarian, may require more extensive or different procedures or treatments. I understand that reasonable efforts will be made to contact me to explain these procedures and treatments and obtain instructions regarding them. However, if the efforts are unsuccessful, I authorize performance of any life sustaining procedures or treatments, which are in the professional opinion of the attending veterinarian. * Yes, I give my permission. No, I do not give my permission. I understand that some risks always exist with sedation and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedures or treatments are initiated. * I have read and agree. I have questions before I agree. I understand that the procedure is monitored with various veterinary devices such as EkG, pulse oximeter and blood pressure to capture vital signs (Temperature, Heart Rate - rhythm and quality, Respiratory Rate - rhythm and depth, SPO2, Capillary Refill Time, Blood Pressure) during the procedure. I give consent to Veterinary Home Care Services to use these veterinary devices to monitor my pet during the procedure if there is no veterinary technician available to assist Dr. Matthew Hejazi. * I have read and agree. No, I do not give my permission. Thank you for filling out our consent form. We look forward to getting your pet back to full health!
