Harbor Road Veterinary Hospital

626 Saint George Road
South Thomaston, ME 04858

(207)354-0266

www.harborroadvet.com

Consent to Treat

Date (required) :
Name (required)
First Name (required)
Last Name (required)
Primary Phone (required)
Phone TypePhone Number (required)
Alternate Phone
Phone TypePhone Number
Pet's Name (required)

Surgical/Anesthetic Procedure You Are Consenting To (required)

Current Medications and Supplements (required)

Consent to Treat Disclosure

By leaving this box checked, you acknowledge that you have read the information in the Consent to Treat Disclosure section of this form.
Electronic Signature - By entering your name in the box below, you are providing consent for the above procedure for the above pet, and that you agree to the payment terms as written in the Consent to Treat Disclosure section. (required)


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