Chemo Consent Form

Please complete the following details.

Chemo Consent Form

Which Clinic are your visiting?(Required)

Patient & Customer Details

Insurance

Do you have Pet Insurance?
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?

Questions

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.
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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?
If "No" I would like to receive an estimate before proceeding today
Payment at Pickup
DD slash MM slash YYYY

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