HAPPY VET ANIMAL CLINIC

CLINICAL CASE RECORD

I. Date
II. Owner’s Identification
Name Telephone/Mobile No.
Address
III. Pet’s Identification
Name Weight Species
Age Breed Color Sex
IV. CLINICAL EXAMINATIONS
A. VITAL SIGNS
Temperature Pulse Rate Respiration Rate
B. OTHERS

V. Tentative Diagnosis Confirmatory Diagnosis

C O N S E N T
To Whom It May Concern,
I, the quick brown fox jumped over the , the undersigned, of legal age, under my own volition
and free will, do voluntarily give consent to submit my pet, Jacques Johann upward, to any diagnostic
test, treatment, operation, and/or all of the forgoing by the member of the clinic staff/veterinarian that I
am willing to pay all the accounts that will be charged by the clinic.
It is understood that whatever the outcome of the procedure, the clinic and the said staff shall not
be held liable for any charges that may be claimed by anyone.

Signature over Printed Name

(Client/Representative)