Ozone Therapy Authorization Form

Owner Name

Chart Number

Address

City/Town

State/Province

ZIP/Postal Code

Phone #

Contact Email

Patient Name

Species

Breed

Age

Color

Sex

Please Initial the Following:

I am either the owner of or responsible for said pet and have authority to give this consent. I am at least 18 years of age. I authorize the performance of Ozone Therapy as you determine to be indicated. I agree to indemnify and hold Scottsdale Veterinary Clinic and its employees harmless from and against any and all liability arising out of the performance of any of the procedures referred to here.

I understand that The Scottsdale Veterinary Clinic cannot guarantee a time that my pet will be available for discharge and that TSVC will ensure to communicate with me a time to pick up.

It is NOT recommended that your pet receive any vitamin supplements up to 12 hours prior to treatment. This may decrease the effectiveness of the treatment.

Phone number where I can be reached today

Print Client Name

Client Signature

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Date

Staff Initials

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Ozone Therapy Authorization Form

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