Procedure Consent Form Patient ID Patient ID as supplied by surgery Estimated Cost I understand that the full balance of the invoice must be settled ON DISCHARGE. The estimated cost I have been given is between: Pet Name Your pets' name: Species Your pets' species: Age Your pets' age: Weight Your pets' weight: Proceedure Authorisation I hereby certify that I am the owner of the above-named animal or am responsible for it and have the authority to execute this consent. I hereby authorise the performance of the following procedure(s):Your Contact Email(Required) Your best contact email Enter Email Confirm Email Your Name(Required) Your Name: First Last Date(Required) DD slash MM slash YYYY Signature(Required) Please sign this form.Preventitives Is your pet due for any preventatives? (Please select Yes or No): Heart Worm? Yes No Vacc Vacc? Yes No Flea & Tick Flea & Tick? Yes No Prevention Pack Would you like a prevention pack with 12 months flea and intestinal worm prevention for a 20% discount? Yes, I'd like a prevention pack. No prevention pack thanks. Deposit Amount Deposit Payment Please enter the amount you wish to deposit today: Total Payment Today: Total Payment Today: Credit Card(Required) Pay With Credit Card:Card Details Cardholder Name NameThis field is for validation purposes and should be left unchanged.
