The Corner Vet
251 Bryanston Drive, Bryanston
T: 011 706 2184
F: 011 706 5466
Postnet Suite # 257
Private Bag X21
Bryanston
2021
Dr Andrew Henning (BVSc)
Dr Jessica Lane (BVSc)
Surgery Admissions Form
Client Name:
I.D:
Patient Name:
Primary Contact Number:_________________________________________________
Secondary Contact Number: _______________________________________________
I grant full and complete authority to The Corner Vet, its Veterinarian(s) and any designated support staff, to provide
the following:
Other Procedures: (please select)
Pre-anaesthetic Blood Tests
Microchip
Vaccination
Deworming
Hernia Repair
Baby tooth removal
Hind Dew Claw Removal
Other (please specify):
Please fill in the following:
Current Food:
Any Tick & flea control:
When last dewormed:
Any medications:
Initials:
____________
The Corner Vet
The Veterinarian has discussed the nature of, reasons for, costs, risks, benefits as well as any potential complications
that could attain from the procedure. I fully understand this information and I am satisfied that my questions and/or
concerns were heard and answered during the discussion of the procedure.
I have left the following with my pet in hospital: (Please select)
Lead: Colour
Collar: Colour
Bedding: Specify
Toys: Specify
Other (please specify):
EMERGENCY CARE
If in the unlikely event that emergency care (including CPR and resuscitation) is required for my pet while he/she is in
hospital and The Corner Vet staff cannot reach me: (Please select)
I give full permission to the veterinarian, and any designated staff to provide the emergency care at my expense.
I DO NOT give permission to provide emergency care at my expense. I fully understand that withholding
permission for The Corner Vet to provide emergency care could cause for my pet to experience serious health
problems and/or death.
PAYMENT
I acknowledge that payment for this treatment/procedure discussed with me telephonically or otherwise, is due (by
cash, credit card or EFT in advance) on discharge of my pet as no accounts will be kept.
(Please select)
I have been given a Cost Estimate of: Between
and
.
I have NOT been told of the cost estimate but will cover all costs necessary of my pet.
To the best of my knowledge, the information provided on this form is true and correct. I am of 18 years or older. I am
the legal owner or the designated agent for the legal owner of, Pets Name:
and have
the authority to sign this consent form.
Please Specify: (Please select)
Owner
Agent of the Owner
Print Full Name
Signature
Date