Please provide our health care team with instructions on how we should proceed if additional medical care is required but we are unable to reach you or your authorized agent (if applicable).
Please read the terms below in full.
Ownership or Agency: I affirm that I am the owner/agent/Good Samaritan responsible for the animal described above, over the age of 18, with authority to execute this authorization form. Services and Updated Authorizations: I authorize and direct the health professionals of Animal Emergency Hospital Volusia (“Hospital”) to undertake medical services which may include, but are not limited to, medical examinations, diagnostics, treatments, procedures and/or humane euthanasia (“Services”), all of which are documented in my client/patient file maintained by Hospital, copies of which I may request and review at any time.
I understand that I can authorize new and/or updated Services associated with my pet’s health condition (“Updated Authorizations”) by phone, electronic communication, in person visit to Hospital, and/or by signing a new and/or updated estimate. I agree and intend that any Updated Authorizations shall immediately attach as a legal and binding addendum to this document as if they were included in my original Authorization, subject to the Terms to which I have agreed herein.
Risks, Adverse Reactions, Refusal to Consent, Untruthful/Incomplete Information & Indemnification: I understand and acknowledge the following: There are risks involved with any and all Services, as well as to my refusal to consent to Services that medical professionals may recommend (“Refusal”); Risks can include the worsening of my pet’s illness or condition, further injury or death (“Risks”); Adverse reactions to Services can result in temporary and/or permanent patient health impairment and/or death (“Reactions”); It is my responsibility to call Hospital or the nearest veterinary healthcare facility should my pet experience any Reactions following discharge from Hospital; I have been encouraged to discuss any questions or concerns I have about Services and potential Risks and Reactions with medical professionals of Hospital before Services are initiated and I certify that I have done so and received answers to my satisfaction; I maintain full financial, medical and legal responsibility for any outcome that results from my Refusal; I certify that I have provided Hospital with completely and totally truthful statements (“Truthful Statements”) regarding all information relevant to the overall health of my pet and the care Hospital shall provide.
To the fullest extent permissible by Florida law, I agree to indemnify, hold harmless and defend the veterinarians, staff, owners and Hospital from and against any and all liability relative to any Services, Risks, Reactions, Truthful Statements and/or my Refusal. Fees, nature of all Services, and the value thereof. I agree to pay all such Fees in full at the time of discharge for Services rendered. If my pet is hospitalized, I agree to pay a deposit of 100% of the highest-end estimated Fees, and assume complete financial responsibility for the balance of Fees at the time of discharge. I agree to pay interest on any unpaid amounts at either 18% annually or the maximum rate allowable by law, whichever is lower. I understand that it is my responsibility to call the hospital at least every twenty-four hours to inquire as to the medical status of my pet and the fees incurred for medical services up to that day.
Rabies: I certify that, unless I have indicated otherwise, to the best of my knowledge my pet has not bitten any person or animal in the last 10 days, and has not been exposed to rabies.
Abandonment: I agree that either I, or an authorized agent on my behalf, will pick up my pet and pay for all accrued Fees upon receiving notification to the contact information maintained in my patient/client file that my pet is ready to be released from the Hospital, unless special accommodations are mutually agreed upon in advance and entered into my patient/client record. I understand that if I fail to comply, Hospital may handle this abandonment in the best interest of the animal and of Hospital, in accordance with the law, and I accept that I will be responsible for all Fees incurred for Services and those resulting from my abandonment.
Care at Home: I acknowledge that any home care instructions have been thoroughly explained to me, and I accept complete responsibility for their implementation and results.
Multimedia: I authorize Hospital to utilize any multimedia whatsoever regarding my pet for its own purposes in any manner as Hospital may deem appropriate. Hospital will initiate flea treatments for an additional charge if fleas are found on my pet, and my agreement to this condition is a prerequisite for my pet receiving Services at this facility.