Urban Vets Animal Hospital

163 Avenue C (at 10th St.)
East Village/Lower East Side
New York City, NY 1009
212-674-6200

VETERINARY CONSENT FORM

Owner’s name: _________________________________________________________

Address: _______________________________________________________________

Street City/State ZIP

Home phone: _______________________ Work phone: ______________________

Emergency phone: ______________________

Pet’s name: _____________________________ Breed: ________________________

Color: ___________ Diet: _______________________________________________

Medical history: _______________________________________________________

_______________________________________________________

Current medications/dosage: ___________________________________________

_______________________________________________________

I am the owner/agent of the pet described above and have the authority to

execute this consent. I authorize the above named veterinary facility and staff to

perform the treatments/procedures described below. I have been informed of the

reasons for the treatments/procedures, along with the expected outcome and the

risks involved.

Procedures: ___________________________________________________________

_______________________________________________________

I understand that there are certain risks to anesthesia and that these risks are

present in any procedure that requires a general or intravenous anesthetic. If

anesthesia is needed, I consent to its use.

The client realizes that in many cases, it is not possible to determine in advance the

exact extent of medical or surgical treatment required for an animal. Urban Vets

will attempt to estimate the cost of the treatment, but it is understood that the final

cost may exceed the estimate, depending on the extent of the treatment required.

The client agrees to pay the balance of the fees due at the time the bill is presented.

If a balance is due and the owner is unreachable, the client consents to having the

charges paid by his/her credit card.

I have read and understood this consent form. I consent to the proposed procedures.

_________________________________________________ _________________

Signature of owner/agent Date