Online Forms

Consent Form

Save time during your next appointment! Complete your required forms online from any device at any time before your visit.

Online Forms

Consent Form

MM slash DD slash YYYY
Owner Name(Required)
Please provide us with all phone numbers where you can be reached while your pet is in our care.

If anesthesia is needed: I understand that there are certain risks to anesthesia and that these risks are present in any procedure that requires a general or intravenous anesthetic. I consent to the administration of sedatives or anesthesia as deemed necessary for safe and humane care. I authorize the doctor on staff and whomever he/she may designate as his/her agent to administer such treatment as is necessary, to perform surgical procedures as deemed necessary, and such additional procedures as are considered therapeutically and/or diagnostically indicated during the course of care. I hereby certify that I fully understand the possibility of complications and inherent risks.

If overnight hospitalization is needed: I hereby certify that I fully understand the possibility of complications and inherent risks during the course of the overnight stay/hospitalization as there will be no on-hand staff to observe the above patient during the duration of the stay. I authorize the above named veterinary facility to admit the above patient for overnight hospitalization/care.

Payment Policy: I realize that in many cases, it is not possible to determine in advance the exact extent of medical or surgical treatment required for an animal. Queens Animal Health will attempt to estimate the cost of the treatment, but it is understood that the final cost may exceed the estimate, depending on the extent of the treatment required. I agree to pay the balance of the fees due at the time the bill is presented. If a balance is due and I am unreachable, I consent to having the charges paid by my credit card on file.

I am the owner/agent of the pet described above and have the authority to execute this consent. I authorize the above named veterinary facility and staff to perform the treatments/procedures described. I have been informed of the reasons for the treatments/procedures, along with the expected outcome and the risks involved. I understand that there is no guarantee as to the results that may be obtained.

I have read and understood this consent form. I consent to the proposed procedures.
This field is for validation purposes and should be left unchanged.