Sample
Your clinic
Informed client consent
Dental cleaning
Patient Maple · Canine · 6 years
Owner Jordan Lee
Bloodwork — Accepted
Dental radiographs — Declined
General anesthesia — Accepted
Owner signature
Not a patient record. Names are invented.
For veterinary clinics
Informed client consent, written before the procedure.
A veterinarian marks what was recommended, what the owner accepted, and what was declined. The owner signs the printed sheet. That sheet goes in the medical record.
Step 1
Choose the clinic
Pick the hospital. Its name, hours, and phone print on the sheet.
Step 2
Mark accepted or declined
Each test and treatment is marked. Nothing is assumed.
Step 3
Print and have the owner sign
The owner signs the paper. That copy stays in the record.
Who it is for
Clinic staff. Pet owners do not sign in. They sign the printed sheet.
What it covers
Examination, diagnostics, sedation, general anesthesia, medications, referral, overnight care, and the procedure itself.
What it is not
It is not a public medical record and it is not overnight monitoring. The clinic’s hours are printed on the form.