TREATMENT CONSENT

FORM
Client information
Owner name [Click/tap here to enter text]

Address [Click/tap here to enter text]

Email [Click/tap here to enter text]

Home phone [Enter number] Mobile phone [Enter number]

Insurance company [Enter text] Policy no. [Enter number]

Patient information
Name [Click/tap to enter text]

Animal ID [Click/tap to enter text] DOB [Click/tap to enter date]

Species [Click/tap to enter text] Breed [Click/tap to enter text]

Colour [Click/tap to enter text] Weight [Enter number]

Sex Female Male De-sexed Yes No

MEDICAL HISTORY

History of Treatment

Known allergies [Click/tap to enter text]

Prior illnesses or surgery [Click/tap to enter text]

Current medications [Click/tap to enter text]

Diet restrictions or supplements [Click/tap to enter text]

ARCACIA / Treatment Consent Form 1/3

Created: 12-05-2016 / Updated: 12-02-2024
Consent declaration
I am the owner/agent of the pet described above and have the authority to execute this consent. I am over
18 years of age. I authorise the above-named veterinary facility 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 TO BE CARRIED OUT

I
[Click/tap to enter text]

understand that there are certain risks to anaesthesia and that these risks are present in any procedure that
requires a general or intravenous anaesthetic. If anaesthesia is needed, I consent to its use.

ESTIMATE PROVIDED
The cost of this procedure is estimated to be $ [Enter number].

PAYMENT POLICY
The client realises that in many cases, it is not possible to determine in advance the exact extent of medical
or surgical treatment required for an animal. ARCACIA vets will attempt to estimate the cost of the
treatment to their best ability, but it is understood that the final cost may exceed the estimate, depending
on the extent of the treatment required. Where the estimate exceeds 10% of the estimate, staff will attempt
to call you to notify you of the reasons and provide an updated estimate.

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 will settle the account by:

Cash Credit card Direct debit VetPay Other credit arrangement

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

ARCACIA / Treatment Consent Form 2/3

Created: 12-05-2016 / Updated: 12-02-2024
Client name [Click/tap to enter full name] Date [Click/tap to enter date]

Signature

ARCACIA / Treatment Consent Form 3/3

Created: 12-05-2016 / Updated: 12-02-2024