Apple Valley Animal Hospital

1207 Cedar Creek Grade
Winchester, VA 22602



Treatment Consent


Please forward all previous records to


Treatment Consent Form

Owner's Name (required)
First Name (required)
Last Name (required)
Treatment Consent Form For (Pets Name): (required)

Date (required) :

I hereby authorize the veterinarians of the Apple Valley Animal Hospital to perform the approved procedure(s) on my pet along with any additional diagnostic and/or treatment procedures as deemed advisable or necessary for my pet. I understand that any additional procedures may increase the final cost. I understand that the hospital requires that all pets have a recent physical examination, be free of all parasites, and be current on vaccinations. I realize that there is always risk when anesthetics and other medications are used if surgery is performed. I understand that results can not be guaranteed. The Apple Valley Animal Hospital has medical staffing: Monday through Friday 7am - 6pm and Saturdays 7am - 5pm. Sundays as needed. If the doctor feels it is necessary, you will be asked to take your pet to the Veterinary Emergency Center for overnight care.
Where can we reach you today? (required)

If my pet is here for an illness or injury, and the doctor feels it is necessary for the diagnosis of my pet. I am authorizing the following: (required)
Laboratory work - I am aware that it could be between $60-$200
X-rays - I am aware that radiographs could be between $200-$325
Call me before performing any services
Payment is due when pets are picked up from hospital.
Initial (required)

Phone number(s) where you can be reached today: (required)
Phone TypePhone Number (required)
Reason for todays visit: (required)
If other, please explain:

Primary symptoms/concerns (please check all that apply): (required)
change in urination
change in drinking
change in appetite
seizure like activity
breathing problems
scratching/skin changes
behavior changes
If other, please explain:

Please give as much detail as possible about your pet’s symptoms: (required)

Does your pet have any medical problems? (required)

Is your pet on any medications, supplements or preventatives? If so, please list: (NA if not applicable) (required)

What is your pet’s current diet? (required)

Does your pet have any allergies? (required)

When is the last time your pet ate? (required)

When is the last time your pet drank? (required)

I agree that I have read all of the information provided on this form and that all of the above information I have provided is true. (required)

Yes, I agree

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