NAZ Pet Emergency - Emergency Treatment Consent Form

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Emergency Treatment Consent Form
Your pet appears to have severe, life-threatening medical emergency and requires immediate emergency treatments.

OUR DOCTOR IS EXAMINING YOUR PET NOW. As soon as your pet's condition allows, the doctor will meet with you and discuss your pet's situation and provide medical recommendation. A fee estimate for further care will also be provided to you.

COST OF IMMEDIATE TREATMENT: The initial treatments required to stabilize your pet's condition, including but not limited to examination, intravenous catheterization, fluid administration, oxygen administration, rapid diagnostic tests, and emergency medication, may range from $800-$900, but can exceed this amount very quickly in critical situations.

PAYMENT INFORMATION: The Veterinary Emergency and Specialty Center of Northern Arizona is unable to offer payment plans or delayed billing. Payment is required at the time that services are provided. We accept payment in the form of Visa, Master Card, Discover, American Express, Care Credit, and cash.
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Please initial the option that you wish below:

Initial I GIVE MY CONSENT FOR IMMEDIATE TREATMENT and I am prepared to make an immediate deposit of $800. I understand that further treatment after this initial stabilization attempt will be additional. The doctor will give me a proposed treatment plan and the staff will discuss the additional financial commitment required. I also understand that an additional deposit will be needed for further diagnostics and treatments.

Initial I DO NOT GIVE MY CONSENT FOR TREATMENT and wish to speak to a doctor first, knowing that such a delay in treatment may be detrimental to the health of my pet. I will not hold Veterinary Emergency and Specialty Center of Northern Arizonaor its staff responsible for any adverse outcome that this delay might cause.
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Pet Name
Owner Name
Email
Witness
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Signature* This field is required.
Clear
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Date* This field is required.
Date
Year
Month
Day
Should be Empty:

Please initial the option that you wish below: