Treatment Authorization Form

Marked fields are required (*)

I authorize Christensen Animal Hospital, Dr. Jeffrey R. Moll and his staff to perform medical and/or surgical procedures required for the diagnosis and treatment of my pet. I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I understand that during the performance of the procedure(s) unforeseen conditions may be revealed that necessitate an extension of the scheduled procedure(s) or different procedure(s) than those originally anticipated and discussed. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian's professional judgment.*
- I DO
I have been advised as to the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed and my financial obligation remains regardless of the outcome. I understand that images of my pet may be used for educational, promotional or diagnostic purposes.*
- I agree
I understand and acknowledge that I am responsible for all fees incurred during this visit. Unless other arrangements have been made, in advance, payment is expected at the time of discharge.*
- I agree
I further authorize Christensen Animal Hospital, to use photos of my pet, and to copyright, use and publish the same in print and/or electronically. I agree that they may use photographs of my pet with or without my name and for any lawful purpose, including for example, as publicity, illustrations, advertising, web content and educational.
- I do
I have read and understand this authorization and consent.*
- Yes
Pet Name:*
Date
MM slash DD slash YYYY
Owner Name:*
First Last
Email*
Emergency phone # the Doctor can reach you at today.*
I Authorize Treatment of my pet. (This acts as digital signature.)*
Yes
Signature*
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Phone
This field is for validation purposes and should be left unchanged.

Treatment Authorization Form

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