Consent for Treatment Form

HAVE YOU TALKED WITH YOUR DOCTOR ABOUT THE FOLLOWING?

1. The medical and/or surgical treatment alternatives for your pet
2. Sufficient details of the procedures for you to understand what will be performed
3. How fully your pet might respond or recover and how long it could take
4. The most common complications and how serious they might be
5. The length and type of follow-up restraint and care required
6. How much this treatment is expected to cost and how payment will be handled

I, the undersigned owner, authorized agent of the owner, or Good Samaritan responsible for seeking veterinary care for the pet identified above, certify that I am over eighteen years of age, and hereby consent to the examination of this pet by staff veterinarians at this veterinary practice. I also agree that after consultation with me, the hospital’s doctors may prescribe medication for, treat, hospitalize, sedate, anesthetize and/or perform surgery on this animal. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated. Should some unexpected life-saving emergency care be required, and the attending veterinarian be unable to reach me, this practice’s staff has my permission to provide such treatment and I agree to pay for all related fees.

I understand that an estimate of the costs for veterinary services can be provided to me at my request and that I am encouraged to discuss all fees attendant to such care before services are rendered and during this pet's ongoing medical treatment. I acknowledge that changes in my pet’s condition or discovery of other findings during treatment may necessitate a change in or an extension of the original estimate and if this occurs, a staff member will attempt to contact me to update this figure. In the event I cannot be reached, this veterinary practice has permission to proceed with medical care for a) a life-threatening condition or b) additional services that will preserve or enhance my pet’s health or c) minimize the need for and risks of additional and costly services to be performed at a later date. If life-saving measures are necessary, I understand I am responsible for any related fees, even in the rare event those efforts are unsuccessful and result in death. I agree to pay the balance of the above estimated fees at the time of my pet’s discharge.

If this animal is hospitalized, a deposit may be required at the discretion of management. In such case, I agree to pay a deposit of 50% of the estimated fees, which will be required at the time my pet is admitted as a patient and assume financial responsibility for the balance of all services rendered on a cash or credit card basis at the time the pet is discharged from the hospital.

Hospitalization

In the event the pet is hospitalized, and the attending doctor is unable to reach me, I understand it is my responsibility to call the hospital to inquire as to the medical status of my pet and the fees incurred for medical services up to that day I understand that veterinary care during nighttime hours and/or weekends is NOT provided. Continuous presence of personnel may not be provided during these hours. If my pet requires overnight or extensive care hospitalization, I understand that he/she will be transferred to a local emergency clinic where overnight veterinary supervision is available at my expense.

I agree that either I, or an authorized agent of mine, will pick up this pet and pay for all accrued charges at the time of discharge. Such notice will be given to the contact information provided on the hospital’s patient client record. I agree that if I fail to comply with this policy, this veterinary practice may handle this abandonment in the best interests of the pet and the hospital. If my pet should not be picked up before the end of the business day, local animal control will be called to assume care and I will still be responsible for costs incurred. Should it become necessary to collect this amount through an attorney or collection agency, the undersigned agrees to pay all costs of collection, including court costs and reasonable collection agency or attorneys’ fees.

I have been advised as to the nature of the procedure(s) or operation(s) and the risks involved. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been encouraged to discuss any questions I may have, have them answered to my satisfaction, and accept that my financial obligations remain regardless of the outcome.