Kiel Veterinary Clinic

575 Belitz Drive
Kiel, WI 53042
office: (920) 894-3414 or (920) 565-2171

fax: (920) 894-7815

www.kielvet.com

 

Medical Consent Form

I am the owner of this animal, and I authorize the following individuals to make medical decisions for this animal in my absence. The following individuals are allowed to have access to medical records. I realize I am financially responsible for their decisions.

Form - Medical Consent Form

Animal Name (required)

Name of Person to make medical decisions in your absence (required)

Name of Person to make medical decisions in your absence

Name of Person to make medical decisions in your absence

Name of Person to make medical decisions in your absence

Owners Name (I agree to the above statement) (required)

Date (required)


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