Consent Form

Veterinary Dermatology Consent Form

We kindly request that you carefully read and fill out the provided consent form for the veterinary dermatology services.

Consent for Veterinary Dermatology Services

Name *

First

Last

Phone *

Email *

Pet's Name *

Species *

Breed *

Is your pet currently taking any medication? *

Consultation Policy

Please note our consultation policy: For all consultations, the pet’s owner and financial decision-maker must be available to speak with the doctor either in person or over the phone during the appointment. If the primary decision-maker is not available to speak with the doctor during the appointment time, the doctor will formulate a plan with their best recommendations based on the information provided. In an effort to serve all our patients, if additional time is needed to reformulate the plan because the primary decision maker was not available during the appointment, additional exam time must be scheduled. *

I understand

GLVD Confirmation & Cancellation Policy

Given our extensive waitlist and in the interest of providing the most timely care for all current and future GLVD patients, GLVD has the following cancellation and confirmation policy. We thank you for your support and understanding. To allow time for rebooking, we kindly ask that any and all appointments needing to be rescheduled or cancelled be done at least 48hrs prior to the scheduled appointment time. We ask that any Monday appointment needing to be cancelled or rebooked be done by the Friday before. All appointments must be confirmed 48hrs prior; unconfirmed appointments are assumed to be unneeded and will be cancelled. Please be aware that any no call/no show appointment prohibits rebooking of this time for the next patient and family in need; thus, any no call/no show appointment will be assessed a cancellation fee equivalent to the consultation fee and/or will be required to pre-pay a non-refundable deposit equivalent to the consultation fee prior to any future appointment. Unless extenuating circumstances, any appointment which is cancelled, rescheduled or left unconfirmed with less than 48hrs advanced notice, may be subject to this same cancellation and/or pre-payment policy. Again, we thank you for your support and understanding. *

I understand

Microscopic Cytology

Microscopic Cytology is a crucial part of dermatologic care and successful management of your pet's condition. Samples of your pet's skin or ears will be taken to be examined on a glass slide to look for types of skin cells, types of infections, and types of inflammatory cells. The results direct the veterinary dermatologist to the best plan of action to diagnose and treat your pet's skin disease. An estimate will be provided after the exam and microscopic cytology for any additional items (cultures, lab work, biopsy, medications, etc.) *

I understand

Authorization and Payment Policy

I hereby authorize the veterinarian to examine, prescribe or treat the above patient. I assume full responsibility for all charges incurred in the care of this animal. I also understand that these charges are to be paid in full at the time of release. Payments are expected when services are rendered. WE DO NOT BILL. In order to provide the best care, we accept all major credit cards (MasterCard, Visa, Amex, & Discover), and cash. Should collection and/or attorney’s fees become applicable I will be held responsible for those and all other costs of collection. By signing below, I hereby state that I am the owner or authorized agent of the above patient. We are teachers in the field of veterinary dermatology. Medical files, case information and/or photos may be used in teaching, continuing education, website, veterinary literature, and the like. I authorize the release of case/patient information for such purposes; client confidentiality (Names and Personal Information) will be maintained. I understand that no guarantee can be made as to the result obtained from medical treatment. I have read the above terms and conditions and agree to adhere to this agreement. *

I agree

Date *

Consent
Form

Consent Form

Veterinary Dermatology Consent Form

Consent for Veterinary Dermatology Services

Consultation Policy

GLVD Confirmation & Cancellation Policy

Microscopic Cytology

Authorization and Payment Policy

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We proudly serve the pets of southeastern Wisconsin & beyond.