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Chapter 3 Veterinary Business Protocols 43

summary of the record is sent to a new veterinarian, spe­ A word about euthanasia forms. These forms must
cialty practice, or even given to the client. The original include a statement that verifies that the animal has not
record remains at the clinic. Medical records are confi­ bitten anyone in the last 10 days. If the animal has it will
dential legal documents and a confidentiality waiver need to be tested for rabies or quarantined for 10 days
ensures that the request for records is made with the before the euthanasia is performed. This is to protect
owner’s knowledge and consent. A copy of the waiver is someone from possibly needing to go through rabies
placed in the paper file or scanned and entered into the prophylaxis. It is also important to check the files on the
patient’s file. A notation of when the waiver was signed patient to make sure the person requesting the eutha­
and when the record was shared is also made in the nasia is the owner. Instances of vindictive euthanasia of a
patient’s file. The file is either printed or copied, mailed pet have occurred.
or emailed to the appropriate person or place.

Reflection
Reflection
Discuss how consent forms could protect the
Discuss the reason why medical records belong clinic from lawsuits.
to the practice but the information belongs to the
client.

Certificates
Forms, Certificates, and Logs The rabies certificate and health certificate are examples
of certificates commonly used in veterinary practice.
Consent Forms Rabies certificates are proof that a rabies vaccine has
been given by a veterinarian, the only person that can
Consent forms are basic contracts that provide evidence legally administer a rabies vaccination. They are vital if
of services requested or agreed upon between the client the animal should bite someone. Without it the animal
and veterinarian. They do not protect against malprac­ can be legally confiscated and either quarantined for 10
tice but do provide proof of services rendered. Most days at the owner’s expense or euthanized immediately
forms will have: to be tested for rabies. It is also important if the vacci­
nated animal is exposed to rabies, such as by being bitten
1. Hospital name, address, phone numbers by a skunk, raccoon, or bat. The animal is usually given
2. Veterinarian’s name – maybe a line if more than one another vaccination and/or quarantined to watch for
doctor is on staff
3. Client’s name, address, phone numbers symptoms.
The certificate can be filled out by staff members, but
4. Patient’s signalment the veterinarian must be the person to sign it to make it
5. Statement that the signee is the owner of the animal valid. The certificate must include the manufacturer,
and is authorized to execute the consent form – type of vaccine, lot and serial number, and expiration
initials required
6. Authorization for the specific service being date. It will also include the animal’s signalment and the
owner’s address and phone numbers, as well as the clin­
provided – initials required
7. Statement about the risks, complications, and ic’s information. The computer will have a printable cer­
tificate that will fill in all this information automatically
irrevocability associated with procedures and that once the vaccine is put into the visit list. The certificate is
the client understands the statement – initials saved under the animal’s name. Paper certificates are in
required
8. Signature and date line for the client to complete. books with triplet copies and need to be filled in by
hand, using a pen. One copy is given to the owner, one is
The form is kept in the medical record; in paper put in the patient’s file, and the other may be sent to
records it is usually the last page and in the computer it animal control authorities or saved if requested.
is scanned and saved to the client’s file. A copy of the A rabies tag with a number, year, and name of the
signed consent form is copied and given to the owner. clinic is also included with the certificate. The tag is to be
Some examples of consent forms include: surgery/ affixed to the patient’s collar and serves to indicate when
anesthesia, boarding, euthanasia, and estimates. The and where the rabies vaccine was given. The number is
AVMA and AAHA have examples of consent forms that filled in on the certificate to assist in finding the certifi­
can be used if the veterinarian is a member of either cate to prove vaccination status. It is for this reason that
organization. rabies tags are dispensed in numerical order.