Treatment Consent Form PhoneThis field is for validation purposes and should be left unchanged.Pet’s NameSpecies Canine Feline AgeSexChart#Owner’s Name First Last Chart#Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Owner’s contactHome phoneCell phoneEmail Best means for communication: Select All Phone Text Messenger Email Consent A Veterinary Client Patient Relationship (VCPR) with Dr B’s Healthy Pets, LLCExplanation of the VCPR can be viewed at www.avma.orgVeterinarian have seen the pet in the past 6-12 months and has enough knowledge to diagnose, prescribe medication, or perform surgical procedures that are in the best interest of the petOwner allows veterinarian(s) to use his/her clinical judgement about your pet’s health to determine a treatment plan, asks questions so you fully understand benefits and risks of treatment, and follow the established treatment plan and allow reassessments as neededDr B’s Healthy Pets must be available to follow up the pet’s case. If after hour emergency care is needed a facility must be identifiedVCPR is no longer valid when there is lack of compliance to 1-3 above, pet owner requests no other treatment for his/her pet, and/or veterinarian(s) chooses to end the VCPRI am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consentI have also been informed that there are certain risks and complications associated with any treatment, operation or procedure. They have been explained to me as well. I further understand that during the treatments, operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional proceduresI authorize the use of appropriate anesthesia and pain relief medication as needed before or after the procedure. I have been informed that there are risks associated with the use of any medicationI understand that Dr B Healthy Pets, LLC may not have the capability to perform all diagnostics in house. In those cases, I understand I will be given the option of being referred for diagnostics or labs may be sent out to reference labsI understand the hospital support personnel will be used as deemed necessary by the veterinarianI have been made aware that treatment is voluntary and only performed when requested and permitted by the pet’s owner/agent. Payments of services are due when services are renderedI understand that my pet’s treatment, operation, or procedure may require an overnight stay. I am aware that no one is on premises overnight. Pets are monitored via video cam and rounds made by personnel. I will not hold the facility or doctor(s) responsible for any loss from theft or natural disaster such as fire, earthquake, tornadoIn the event of an adverse reaction or need of CPR due to cardiac and/or respiratory arrest, I give permission to Dr B Healthy Pets staff to perform services as needed and I agree to charges for such servicesI am aware that all pets must have a current Rabies vaccine for the protection of the staff and to adhere to our county and state guidelinesI understand I the owner is the responsible party and must give consent. However, during my absence, I give permission to the following to act on my behalf as the agent for the owner of the pet(s) listed aboveSigned First Last Date MM slash DD slash YYYY