Cushings Consent Form | The Village Vet Killara and Pymble

Cushings Consent Form

Please complete the following details.

ACTH Stim Test and Low dose Dexamethasone Suppression Test 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.

Insurance Provider

Insurance Policy Number

Questions

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

What strength trilostane are you giving your pet? (mg or mg/ml)

How much trilostane do you give? (mls or number of tablets)

How frequently do you give the trilostane? (times per day)

What time was the trilostane tablet or liquid given today?

How much medication do you have left at home?

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

When did your pet last eat?

Is your pet up to date with tick/flea prevention?

Yes

No

Unsure

Approvals

Your pet is being admitted into hospital today for a procedure or hospital treatment as outlined above. The vet will call with the results over the next few days.

Payment at Pickup

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

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

Date

DD slash MM slash YYYY

Estimate provided by vet

Yes

No

Need help with this online form?

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

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