Case Study Patient Consent Form

You are being asked to consider allowing Tri-C Veterinary Technician student Stacie Collins, interning at West Park Animal Hospital, to use information about your pet Daisy and to write what is called a case study. Case studies are typically used to share new unique information with other students and school faculty. This case study will be written for other students to read, and/or presented in class. This form explains the purpose of this case study. Please read this form carefully and take your time to make your decision and ask any questions that you may have.

Your pet’s information being used for this case study includes radiographs, signalment and outcome on her Dentigerous Cyst.

West Park Animal Hospital and Stacie Collins are obligated to protect your privacy and not disclose your personal information (information about you as an individual e.g. name, address, etc.). When the case study is published or presented, your identity will not be disclosed.

Taking part in this case study is your choice (voluntary). You may choose not to take part, your decision will not result in any penalty or loss of benefits to which you are entitled including the quality of care your pet receives.