Blood Glucose Informed Consent Form

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Pet's Name:

Pet Parents First Name:

Last Name:

Best Phone Number to reach you today:

Secondary Phone Number:

Please read and check each box to indicate your agreement with each applicable statement.

I, the undersigned, owner or responsible party of the admitted patient, hereby authorize the veterinarians of Parkland Veterinary Clinic (and whomever they may designate as assistants) to administer such treatments as necessary, and to perform any additional procedures as are therapeutically and/or diagnostically necessary as indicated by findings during medical evaluation.

Statement Approval

I understand that in cases where further, unforeseen work is required and is of non-emergency nature (additional diagnostics, changes to treatment plans etc.), every attempt will be made by the veterinarians/staff to contact the owner by phone to discuss the case. I also understand, if contact cannot be made in a timely manner, no additional work will be performed until informed verbal or written consent can be obtained. Once contacted and if I verbally agree with the recommended procedure, I grant authority for the purpose of remedying conditions that are not known at this particular time, but which may become evident while the patient is in hospital.

If your pet requires overnight hospitalization, , please read the following statements and check each box that applies:

I understand and accept that there is no overnight staff on duty after the hospital closes, and that my pet will be attended to the following morning. OR

I prefer to take my pet to a 24-hour emergency/specialty clinic for overnight monitoring

When was your pet’s last meal?

What type of Insulin does your pet receive? (Caninsulin / Basaglar / etc.)

When was your pet’s last insulin dose?

How much insulin was given?

How many times a day do you give insulin

Have you recently adjusted the dose at home?

Have you noticed any Vomiting?

Have you noticed any Diarrhea?

to you

Have you noticed any Lethargy?

Change in eating habits?

Change in urination habits?

Change in water consumption?

Any Additional Notes

Statement Approval

I hereby certify that I have read and fully understand the above authorization for medical and/or surgical treatment, and that the above procedure has been explained to my satisfaction and I have no further questions or concerns.

Statement Approval

I also certify that no guarantee or assurance has been made regarding the results that may be obtained. I acknowledge that any post-surgical or post-anesthetic complications may require additional veterinary care or medications. Further, I assume full financial responsibility for all charges incurred to this patient.

Owner/Responsible Party of Admitted Animal Signature

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