Treatment Plan Agreement Client InformationClient NameAddress Street Address City State / Province / Region ZIP / Postal Code Phone NumberPatient InformationPatient NameSpeciesBreedSexColorWeightIs your pet spayed/neutered? Yes Date MM slash DD slash YYYY An itemized treatment plan has been sent to you for your pet's care. The cost associated with this treatment plan is provided below. The low total is taken as a deposit prior to hospitalization. Payment in full is due at time of discharge. This is an estimate only, and subject to change based on your pet's condition. If you have questions, please contact your medical team at 303-660-1027.Estimated Cost of 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 I ... DO AUTHORIZE CPR efforts for my pet DO NOT AUTHORIZE CPR (DNR) efforts at this time Owner/Agent Signature(Required)CommentsThis field is for validation purposes and should be left unchanged. Δ
