Consent for Treatment and/or Admission, Photo Use DECLINED

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Patient Information

Is your pet spayed/neutered?
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I, the undersigned owner, or authorized agent of the owner 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 Veterinary Specialists of the Rockies (VSR). I also agree that after consultation with me, the hospital’s doctors may initiate treatment on my pet. Should some unexpected life-saving emergency care be required and the attending veterinarian is unable to reach me, this practice’s staff has my permission to provide such treatment and I agree to pay for all related fees. No certain outcome is guaranteed in veterinary medicine. I am also aware that certain breeds may have higher risk during procedures or treatment due to their physical conformation. I understand that I can terminate treatment at any time by contacting my pet’s attending doctor.

I understand that an estimate of the costs for services will be provided to me and that I am encouraged to discuss all fees associated with care. If this animal is hospitalized, I agree to pay a deposit of the estimated fees and assume financial responsibility for the balance of all services rendered at the time of discharge. A service fee of $5.00 and 1.5% of the outstanding balance will be charged to your account monthly if not paid in full. If applicable, I will be responsible for any lawyer and/or collection agency expenses that may be incurred. If my hospitalized pet’s attending doctor is unable to reach me, I understand it is my responsibility to call the hospital at least once every twenty-four hours to inquire as to the medical status of my pet and the fees incurred for medical services up to that day.

If a different veterinarian has referred me to Veterinary Specialists of the Rockies, I understand that my pet’s medical records will be sent to them for continuation of care without interruption. I also give permission for Veterinary Specialists of the Rockies to release my pet’s medical records to my general health veterinarian that I state upon check-in. In the event I relinquish my pet, I authorize transfer of medical records to the new owner.

I acknowledge that the staff of Veterinary Specialists of the Rockies perform continuing education for the veterinary community, but DO NOT authorize the staff to use medical information and photos for teaching, veterinary literature and social media.

Payment is due at time of service. I understand that as the owner or agent, I am financially responsible for all charges relating to this patient. I have read and agreed to this treatment authorization and have agreed to the financial obligations.

Cardiopulmonary Resuscitation (CPR) Directive

I understand Veterinary Specialists of the Rockies (VSR) requires a CPR status prior to the start of any and all procedures so immediate action can take place in the event of cardiopulmonary arrest during, before, or after anesthesia or anytime in our care. I acknowledge that the attending veterinarian or staff members of VSR will make every effort to contact me regarding treatment in the case of this unforeseen event. The starting cost of CPR is approximately $400.

I am the owner / agent of this pet and ...
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