SOUTHERN CROSS VETERINARY CLINIC INFORMED CONSENT TO TREATMENT
1. I, the undersigned, an adult major, hereby authorize the veterinarians and staff of this veterinary facility
to perform any reasonable treatment / anaesthesia and surgery they may deem necessary, including
further or alternative measures as may be necessary during the course of the surgery and/or treatment
of my animal.
2. I recognise that there is some degree of risk attached to any medical or surgical procedure or treatment.
I have discussed any concerns I may have with the veterinarian. I hereby absolve the veterinarians,
staff and this facility from all actions, arising directly or indirectly from the treatment / anaesthetic /
surgery.
3. I am aware that this veterinary facility does not provide 24-hour per day on-site monitoring of patients.
Should I wish to have my pet monitored 24 hours per day while hospitalised, I will make arrangements
with the staff of this facility.
4. I undertake to keep in daily contact to enable the staff to inform me of the progress, costs incurred,
and additional treatment involved, of my hospitalised animal.
5. I acknowledge that your account is payable upon presentation.
6. I am aware that I may request an estimate of the costs involved, and that interest will be charged
on overdue accounts from 30 days after presentation of the first account.
7. I acknowledge that I am indebted to the above practice for veterinary treatment, services rendered
and expenses incurred therewith and hereby render myself responsible for all costs, telephone calls
and legal expenses, as between attorney and own client, including collection charges that may be
incurred in the recovery of the outstanding amount.
8. In the event of any grievance or dispute with this veterinary facility or its veterinarians, I undertake to
enter into and complete the VDA’s free Alternate Dispute Resolution process, before resorting to any
other action or remedy.
9. I acknowledge that I have read these conditions and hold myself bound thereto.
NAME OF PET: ………………………………………………
AGE: ………………….. SEX: ……………… BREED: ………………………………….…
ENVISAGED PROCEDURE: ...………………………………………………………….........…………..
IT IS ADVISABLE THAT ALL SENIOR PETS (7 YEARS OF AGE AND OLDER) UNDERGO A PRE-ANAESTHETIC BLOOD TEST. PATHCARE INVOICES YOU DIRECTLY. COST OF BLOOD TESTS IS: R540-R600. THERE IS AN ADDITIONAL CHARGE OF R150 FOR BLOOD COLLECTION. YES / NO
HAS YOUR PET SHOWN ANY UNUSUAL SYMPTOMS? YES / NO
IF YES, PLEASE GIVE A BRIEF DESCRIPTION OF ANY ABNORMALITIES ......................................
............................................................................................................................
ESTIMATE OF THE COSTS FOR TREATMENT: ...........................................................................
IN ORDER TO ASSIST US WITH ADMIN, PLEASE CIRCLE THE APPROPRIATE METHOD OF PAYMENT.
CASH/CARD/CHEQUE/TRANSFER ( Clients settling by EFT are requested to provide proof of payment
upon discharge.)
FULL NAME OF OWNER / LEGAL AGENT
…………………………………………………………………………………………………………..........…
I.D. NO: ……………………………………………………….........................................
POSTAL ADDRESS: .........................................................................
PHYSICAL ADDRESS: .....................................................................
EMAIL ADDRESS: ..........................................................................
HOME TEL: ………………………….....……… WORK TEL: …………………………….….
CELL: ……………………………………......…..
SIGNED: ………………………………......…… DATE: …………………………………...….
WITNESS: .................................. DATE: ..................................
1. I, the undersigned, an adult major, hereby authorize the veterinarians and staff of this veterinary facility
to perform any reasonable treatment / anaesthesia and surgery they may deem necessary, including
further or alternative measures as may be necessary during the course of the surgery and/or treatment
of my animal.
2. I recognise that there is some degree of risk attached to any medical or surgical procedure or treatment.
I have discussed any concerns I may have with the veterinarian. I hereby absolve the veterinarians,
staff and this facility from all actions, arising directly or indirectly from the treatment / anaesthetic /
surgery.
3. I am aware that this veterinary facility does not provide 24-hour per day on-site monitoring of patients.
Should I wish to have my pet monitored 24 hours per day while hospitalised, I will make arrangements
with the staff of this facility.
4. I undertake to keep in daily contact to enable the staff to inform me of the progress, costs incurred,
and additional treatment involved, of my hospitalised animal.
5. I acknowledge that your account is payable upon presentation.
6. I am aware that I may request an estimate of the costs involved, and that interest will be charged
on overdue accounts from 30 days after presentation of the first account.
7. I acknowledge that I am indebted to the above practice for veterinary treatment, services rendered
and expenses incurred therewith and hereby render myself responsible for all costs, telephone calls
and legal expenses, as between attorney and own client, including collection charges that may be
incurred in the recovery of the outstanding amount.
8. In the event of any grievance or dispute with this veterinary facility or its veterinarians, I undertake to
enter into and complete the VDA’s free Alternate Dispute Resolution process, before resorting to any
other action or remedy.
9. I acknowledge that I have read these conditions and hold myself bound thereto.
NAME OF PET: ………………………………………………
AGE: ………………….. SEX: ……………… BREED: ………………………………….…
ENVISAGED PROCEDURE: ...………………………………………………………….........…………..
IT IS ADVISABLE THAT ALL SENIOR PETS (7 YEARS OF AGE AND OLDER) UNDERGO A PRE-ANAESTHETIC BLOOD TEST. PATHCARE INVOICES YOU DIRECTLY. COST OF BLOOD TESTS IS: R540-R600. THERE IS AN ADDITIONAL CHARGE OF R150 FOR BLOOD COLLECTION. YES / NO
HAS YOUR PET SHOWN ANY UNUSUAL SYMPTOMS? YES / NO
IF YES, PLEASE GIVE A BRIEF DESCRIPTION OF ANY ABNORMALITIES ......................................
............................................................................................................................
ESTIMATE OF THE COSTS FOR TREATMENT: ...........................................................................
IN ORDER TO ASSIST US WITH ADMIN, PLEASE CIRCLE THE APPROPRIATE METHOD OF PAYMENT.
CASH/CARD/CHEQUE/TRANSFER ( Clients settling by EFT are requested to provide proof of payment
upon discharge.)
FULL NAME OF OWNER / LEGAL AGENT
…………………………………………………………………………………………………………..........…
I.D. NO: ……………………………………………………….........................................
POSTAL ADDRESS: .........................................................................
PHYSICAL ADDRESS: .....................................................................
EMAIL ADDRESS: ..........................................................................
HOME TEL: ………………………….....……… WORK TEL: …………………………….….
CELL: ……………………………………......…..
SIGNED: ………………………………......…… DATE: …………………………………...….
WITNESS: .................................. DATE: ..................................