780-250-1700
2531 – 17th Street NW Edmonton, AB
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Blood Glucose Curve – Drop Off Consent Form
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Blood Glucose Curve - Drop Off Consent Form
Please fill out ALL the subject fields below prior to your pets blood glucose curve appointment. Please contact us if you have any questions or concerns.
Client (Owner) Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
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Antarctica
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Panama
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Virgin Islands, U.S.
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Phone
*
Patient Name
*
Breed
*
Color
*
Sex
*
Male
Neutered Male
Female
Spayed Female
Age
*
Please specify weeks/months/years
*
Weeks
Months
Years
Date of last dose of insulin:
*
Time of last dose of insulin (am/pm):
*
Amount of insulin that was given at last dose:
*
What type of insulin are you giving your pet?
*
What is your insulin schedule (ex: 2 units twice daily):
*
Is your pet eating/drinking normally?
*
Please describe any changes in detail
Have you noticed any changes in your pet's behaviour?
*
Please describe
Consent
*
We are a Fear Free Certified Clinic that aims in reducing fear, anxiety and stress in our patients. If we notice that your pet is showing any signs of these, we automatically request that your pet gets some anti-anxiety/calming medication prior to their sedation. (Please be aware that you are responsible for the costs of this – it varies depending on weight of animal and breed.)
I do not consent to Fear Free methods
Consent
*
I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above, that I do hereby give Suzanne Misiaszek DVM, her associate doctors, agents, employees, students and/ or representatives full and complete authority to perform the procedure(s) described as above
I do not provide consent to the doctors to perform the procedures as described above
Consent
*
FURTHERMORE, I UNDERSTAND THAT DURING THE PERFORMANCE OF THE PROCEDURE(S) THAT I HAVE AUTHORIZED, UNFORESEEN CONDITIONS MAY ARISE. THEREFORE, I HEREBY CONSENT TO AND AUTHORIZE THE PERFORMANCE OF SUCH PROCEDURES AS ARE NECESSARY IN THE EXERCISE OF THE VETERINARIANS PROFESSIONAL JUDGMENT. I ALSO DO HEREBY ACKNOWLEDGE THAT I UNDERSTAND THAT THERE ARE NO GUARANTEES EITHER EXPRESSED OR IMPLIED THAT THE PROCEDURES AUTHORIZED WILL BE WITHOUT COMPLICATIONS FROM UNEXPECTED EVENTS BEYOND THE VETERINARIANS AND HOSPITAL’S CONTROL.
I do not consent to the unforeseen risks involved with this procedure
Signature
*
Date
*
Date Format: MM slash DD slash YYYY
Best number to reach you at during the appointment time:
*
Home
Contact
New Clients
What to Expect
New Client Registration Form
Prescription/Food Refill Request
About Us
Team and Pet Bios
Location & Hours
Make an Appointment
Fear Free Clinic
Services
Medical Services
Surgical Services
Anesthesia and Patient Monitoring
Nutritional Counseling
Additional Services
Pet Health
Pet Health Library
Pet Health Checker
How-To Videos
News
Forms
Consent Forms
General Anesthesia Consent
Euthanasia Consent Form
Echocardiogram – Drop Off Consent Form
Drop Off Consent Form – with sedation
Drop Off Consent Form
Overnight Hospitalization – Drop Off Consent Form
Blood Glucose Curve – Drop Off Consent Form
Dental Surgery Consent Form
Spay/Neuter Surgery Consent Form
Telemedicine Consent Form
Ultrasound Consent Form
Admission Forms
Canine Patient Admission Form
Feline Patient Admission Form
Recheck Exam Admission Form
Questionnaires
Diarrhea Questionnaire
Vomiting Questionnaire
Itching Questionnaire
Canine Cognitive Dysfunction Syndrome Assessment
Shop Online
Contact Us
Name
*
First
Last
Email
*
Phone
*
Pet Name
*
Preferred Date
*
MM
DD
YYYY
Preferred Time
*
:
HH
MM
AM
PM
Reason for appointment
*