EASTSIDE ANIMAL MEDICAL CENTER

___ Military or ___ Educator (Must show identification)

I authorize the Doctor and or staff at EASTSIDE ANIMAL MEDICAL CENTER to administer treatment and medication as

is considered necessary. I will honor all financial commitments incurred in the diagnosis and treatment of the patient

above and understand that all financial obligations will be satisfied prior to the dismissal of the patient. I understand that

If my pet experiences cardiac and/or respiratory arrest (lack of heart beat and/or breathing), I request the veterinarians and staff of EASTSIDE ANIMAL MEDICAL CENTER to perform CPR in an attempt to restore heart and/or respiratory

function. I understand that medications, equipment, and procedures utilized during CPR attempt will be billed in addition to

the estimate given for examination, medications, and treatments – and will generally result in an additional expense of

$500.00 or greater. I have read the above authorization and fully understand the reason for medication and or treatment. I

have been informed of potential complications and the fees that will be incurred in the course of treatment.

I understand that ALL EMERGENCY CLIENTS / PATIENTS MUST RETURN to their primary veterinarian for ALL

follow-up treatment, including prescription refills. Patients not picked up by 8:00 am on day of dismissal, will

incur a late discharge fee of $20.00 per hour. All records will be sent to your primary veterinarian.

A monthly service fee of 1.5% will accrue on all unpaid balances.

This form MUST be signed. If this form is not signed then treatment can NOT be started on your pet and form will need to be resubmitted for completion. This may cause delays in your pets' treatment.