Treatment Release

Client Name:*

Phone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pet's Name*

Dog or Cat

All animals entering the hospital must be current on vaccinations and free of external parasites or they will be treated at the owner’s expense.

Medication to be administered:*

Procedures to be performed:*

In the event of an Emergency I wish for CPR to be performed on my pet: I understand that medications, equipment, and procedures utilized during CPR attempt will be billed in addition to the estimate given for examination, medication, and treatments – and will generally result in an additional expense of $150.00 to $300.00.*

YesNo

Please Initial*

I authorize this hospital to perform the above-mentioned medical procedures(s) required for the diagnosis and treatment of my pet.

I also authorize the use of appropriate anesthesia, and other medication, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I understand that during the performance of the following procedures(s) unforeseen conditions may be revealed that necessitate an extension of the foregoing procedures(s), or different procedures(s), than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgement. I understand that I can terminate treatment at any time by contacting the attending veterinarian.

I have been advised as to the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed and that my financial obligation remains regardless of the outcome.

I agree to pick-up my pet within five (5) days of the discharge date, and my pet may be considered abandoned, if I do not pick my pet up within those 5 days. In my failure to recover my pet, the hospital is authorized to dispose of my pet as deemed professionally necessary. Pets are only released during regular business hours of 7:30am to 5:30pm EST.

Full Payment is due upon release of the pet. A monthly service fee of 1.5% will accrue on all unpaid balances.

I have read and understand this authorization and consent. My signature below constitutes my acknowledgement that (i) I have read and agreed to the above, (ii) the procedure(s) have been explained to my satisfaction and that I have all the information that I desire, (iii) I have had the chance to ask questions, (iv) I have been given an alternative plan with the inherent risks of selecting the alternative plan, and (v) I authorize and consent to the performance of the procedure(s) listed in the treatment plan (estimate) and to the administration of anesthesia or sedation when deemed necessary.

Best #:*

2nd best #:

Signature owner/agent:*

Date*

Date

Eastside Animal Medical Center

Treatment Release Form