I authorize the veterinarian(s) on duty at the Regional Veterinary Referral Center/ Critical Care Unit (RVRC/CCU) and the assistants they may designate, to examine the animal specifically described and identified, and I assume financial responsibility for this exam ($219.00). In the event the animal requires additional treatment considered therapeutic and/or diagnostically necessary on the basis of the findings, I understand that a full care plan will be prepared listing subsequent fees. I assume financial responsibility for all charges incurred for the services rendered to the patient and understand that payment is due at the time services are rendered. I authorize the RVRC/CCU to share pertinent medical records with other veterinarian(s) involved in the care of the animal both inside and outside of the RVRC/CCU. I also grant the RVRC/CCU, its representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. All information on this form has been filled out truthfully and to the best of my ability. I have read and understand the above.