Client Consent Form

By signing this form below:

1. I certify that I have full and exclusive authority to make all decisions relating to the animal(s) named under my name below (collectively, "PET").
2. I authorize Midwest Veterinary Dermatology Center (MVDC) to perform the following procedure(s):
   Exam and related diagnostics, including, without limitation, the administration of sedatives and anesthetic agents as deemed appropriate by the attending veterinarian(s). I understand that the treatment(s) I am hereby authorizing may be performed by veterinarian(s) different from the veterinarian(s) who have previously examined my pet and/or that others may assist in such treatment(s), and in each case, I authorize the same.
3. I acknowledge that the nature, purpose, benefits, and reasonably foreseeable risks of the foregoing treatment(s), post-treatment(s) care requirement(s), available alternate treatments, and the risks and consequences of no treatment, all have been satisfactorily explained to me, including, without limitation, reasonably foreseeable risks relating to anesthesia and my pet's recovery.
4. If conditions arise which, in the judgement of the attending veterinarian(s), call for procedure(s) and/or treatment(s) other than those now being authorized, I also authorize such procedure(s) or treatment(s), including those needing to be performed by referral to Veterinary Specialty Center, Inc., and agree to be financially responsible for same and any other veterinary care the attending veterinarian(s) determine(s) is required by any complications. (MVDC will use reasonable efforts to contact me to consent to the same to the extent practicable.) I acknowledge that no guarantee or assurance has been made regarding the outcome and will pay for treatment regardless of outcome, including fees incurred at Veterinary Specialty Center, Inc.
5. I give my permission to release case/patient information and/or photos so they may be used in teaching, continuing education, website, veterinary literature, and the like. Except as provided in the preceding sentence, patient confidentiality will be maintained.
6. I understand that any personal belongings left with my pet may not be returned and that I'm encouraged to take all belongings with me, including leashes, collars, bedding, and toys. If items become soiled, we may have to dispose of them for sanitary reasons.
7. I hereby waive, both for myself and for each other person mentioned in section 9(b) below, each right, claim, remedy, privilege and benefit, of whatever nature and whenever arising, that is inconsistent with this authorization; and will pay, reimburse, indemnify, defend and hold harmless mvdc from each loss, damage, liability and/or expense (whether or not from third party claims, and including in each case reasonable attorneys' fees, costs and disbursements) incurred by mvdc, arising out of, based upon and/or resulting from the inaccuracy of any certification and/or statement made herein and/or in my pet's admission form(s) and/or any claim made by myself or any of the persons mentioned in section 9(b) below against mvdc that is inconsistent with this authorization; and agree that for the purposes of this section 8, "Mvdc" includes midwest veterinary dermatology center. The MVDC facility owner, and their respective equity members, directors, officers, managers, veterinarians, employees, contractors, affiliates, partners, patients, clients, invitees, tenants, insurers, successors, representatives, attorneys, agents, and assigns.
8. I certify that:
   (a) I have read this Authorization and understand its contents before signing below;
   (b) this Authorization is effective and binds myself and my spouse, family members and heirs, and their respective insurers, successors, representatives, attorneys, agents and assigns, and any person claiming through any of the foregoing and/or pet; and
   (c) My obligations hereunder are in partial consideration for my pet's treatment at MVDC.