Chemo Consent FormWhich Clinic are your visiting?(Required) Pymble Killara Patient & Customer DetailsPatient NamePatient Weight TodayCustomerAddressPhoneAlternate Contact No. if different for today:InsuranceDo 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 NameInsurance Policy NumberQuestionsHow 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: Add RemoveClick Plus to add more than one medication.When did your pet last eat?This field is hidden when viewing the formSignatureYour 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 acceptanceOwners signature (or carer over 18yrs of age):(Required)Date DD slash MM slash YYYY CAPTCHA
