Veterinary Transport Consent

Date

MonthDayYear

Owner Name

First NameLast Name

Pet's name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

I am authorized to execute this consent in my capacity as owner/agent of the owner of the Patient named above.

I authorize and direct Capital Veterinary Specialists.LLC, a Florida limited liability company, and its agents and representatives (collectively, "CVS"), to transport the Patient in a CVS transportation vehicle to CVS' veterinary hospital located at 1615 Mahan Center Blvd, Tallahassee Fl, 32308 or, if determined to be more appropriate in CVS' sole discretion, to another CVS clinical location (the "Location") for eveluation and treatment.

During such transportation and upon arrival at the Location, I further authorize and direct CVS to provide the Patient with such emergency care, medicaitons and procedures, including, without limitations, surgical procedures, as are considered therapeutically and diagnostically necessary by CVS; provided, however, that CVS will use reasonable efforts to consult with me regarding non-emergency care, medications, and procedures for the Patient prior to providing the same.

I, in my capacity as or on behalf of the owner of the Patient as the owner's duly authorized agent, as applicable, asusme full financial responsibility for all charges incurred by the Patient in relation to the Patient's transportation to the Location and the care, medications and procedures provided to the Patient during such transportation and following such transportation at the Location. I understand and agree that payment for such charges is due in full no-later than the time of the Patient's discharge from the Location.

Transportation fee of the Patient to and from Capital Veterinary Specialists: $91.85

Except in the case of CVS' willful misconduct or gross negligence, I, in my capacity as or on behalf of the owner of the Patient as the owner's duly authorized agent, hereby irrevocably waive and disclaim any and all responsibility and liability of CVS for any and all damages and injuries to, related to or arising from the Patient, or caused by any action or inaction of CVS in, the transportation of the Patient to the Location (and, if applicable, the transportation of the Patient back to its owner).

Please initial below regarding how you desire CVS to respond if the Patient experiences cardiac arrest and then sign and date the Veterinary Transport Consent.

I DO NOT blanks request resuscitation performed on my animal.
I DOblank request resuscitation performed on my animal.

Transport Consent Form