HSWC Clinic Consent Form

Your Name

Email address

Phone number 1

Phone number 2

Address

Pet's Name

AGE

Breed & Color / Markings

ONLY IF you are requesting a Microchip- Fill out this section with name/phone number of someone other than yourself who can be an Emergency Contact. We will register it for you.

PLEASE READ AND CONSENT TO THE FOLLOWING:

1. I am the owner of the animal(s) presented for services and have the authority to execute this consent and authorize the performance of the requested procedures. I understand the staff of the Humane Society of Waupaca County will perform the procedure(s) to the best of their ability, always taking into account the safety of the animal(s) first.
2. To the best of my knowledge my animal(s) have no diagnosed allergies to vaccines. I will inform the Veterinarian and staff of any current medical conditions or medications that may increase my animal(s) chance for adverse reactions to vaccinations. I understand that the Humane Society of Waupaca County uses only the highest quality of vaccines available; and I am aware vaccine reactions are possible, though they are rare.
3. Should my animal(s) become ill due to vaccines, I will not hold the Humane Society of Waupaca County, its affiliates, or employees responsible. I agree to treat any medical concerns/conditions or vaccine reactions at my own Veterinarian or emergency clinic and am aware that this will be my own financial responsibility.
4. I understand that this is not a full and complete exam and for the overall health of my animal(s). Your animal(s) have been examined to determine the appropriateness of vaccinations selected. A comprehensive exam should be performed yearly at my local Veterinarian.
5. My animal(s) have had no recent occurrences of abnormalities such as coughing/sneezing, vomiting/diarrhea, runny eyes/nose, or fever. I certify that my animal(s) is in good health.
6. We have the right to refuse services if it will cause harm to your animal(s). If an illness is identified, be aware your animal(s) vaccines may be delayed until said illness is addressed at your own Veterinarian.