Chemo Consent Form | The Village Vet Killara and Pymble

Chemo Consent Form

Please complete the following details.

Chemo Consent Form

Which Clinic are your visiting?(Required)

Pymble

Killara

Patient & Customer Details

Patient Name

Patient Weight Today

Customer

Address

Phone

Alternate Contact No. if different for today:

Insurance

Do you have Pet Insurance?

Yes

No

If you wish to claim for today please let a nurse or receptionist know and we can submit it electronically for you.

Would you like us to make GAP claim for you?

Yes

No

Insurance Company Name

Insurance Policy Number

Questions

How has your pet been? Any recent changes or issues you would like us to tell the vet about?

Eg did your pet vomit/go off food or have diarrhoea after the last visit? If so for how long?

Please record any current medications your pet is on and when the medication was last given:

Click Plus to add more than one medication.

When did your pet last eat?

This field is hidden when viewing the form

Signature

Your pet is being admitted into hospital today for a procedure or hospital treatment as outlined above. The vet or nurse may also call you with further updates and necessary treatments.

Estimate provided by vet?

Yes

No

If "No" I would like to receive an estimate before proceeding today

Yes

Payment at Pickup

I agree to payment of the fees when I collect my pet from the clinic.

Please type your full name for acceptance

Owners signature (or carer over 18yrs of age):(Required)

Date

DD slash MM slash YYYY

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For more information regarding orders or our services, please contact us.

Call Killara: (02) 8350-5678 Call Pymble: (02) 9499-4010