Authorization for Critical Care treatment Client InformationClient Name Address Street Address City State / Province / Region ZIP / Postal Code Phone Patient InformationPatient Name Species Breed Sex Color Weight Is your pet spayed/neutered? Yes Date MM slash DD slash YYYY Your pet presents in critical condition. Please sign one of the two following agreements. I authorize immediate Critical Care Treatment and accept financial responsibility. I am the owner or agent for this pet and am over 18 years of age. I wish to initiate or continue Critical Care Treatment, including but not limited to: IV catheter placement and fluid therapy, pain control, shock treatment and medications, laboratory evaluation and/or radiographs. I do NOT wish to have Critical Care Treatment provided until I have spoken with the doctor and have been provided with an estimate of all expected charges. I understand this may delay critical care treatment that may be necessary to save the life of my pet. I assume all risks of delay. Further, I release the doctor, Veterinary Specialists of the Rockies and its staff/contracted agents from liability from any complications related to my choice to delay treatment. Cardiopulmonary Resuscitation (CPR) DirectiveI 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 ... DO AUTHORIZE CPR efforts for my pet DO NOT AUTHORIZE CPR (DNR) efforts at this time The initial costs of Critical Care stabilization are estimated at $750. This estimate is for initial stabilization only and does not include continued care once your pet is stabilized nor, does this estimate include hospitalization, treatments, medications or follow-up care. These initial costs also do not guarantee a positive outcome. PAYMENT FOR EMERGENCY STABILIZATION IS REQUIRED UPON AUTHORIZATION. The doctor will speak to you as soon as reasonably possible and will provide you with a written estimate of the total expected charges, including emergency treatment. Your payment for emergency treatment will be applied to the total costs. A deposit for the low end of the estimate will be required to continue treatment. WE DO NOT OFFER ANY PAYMENT PLANS, however third-party financing options may be available to you for more extensive care.Owner/Agent Signature(Required)CommentsThis field is for validation purposes and should be left unchanged. Δ
