Rescue Authorization Sheet

Consent Form for Authorized Treatment

Please submit this form 24 hours prior to the patient's appointment .
Pet(s) Appointment Date. *

MonthDayYear
Date
Foster's Full Name*

First NameLast Name
Foster's Phone Number*

Area CodePhone Number
Pet's Name*
Sex*

Male IntactFemale IntactMale NeuteredFemale Spayed
Pet's Color*
Pet's Breed (i.e. Pointer, German Shepard, Domestic Short Hair, etc)*
Pet's Species*

CanineFeline
Pet's Weight*
Pet's Age (Estimated)*
Pet's Date of Birth

MonthDayYear
Date
Upload Medical Records (Please upload records or email them to hospital@urbanpetvet.net)

Browse Files

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Pet's Photo for File (Optional)
We authorize the following treatments for the patient listed above*

Sick Appointment (List concerns in the next question)RabiesBordetellaDHPPLeptoMicrochipFlea/Tick Preventative (1 month supply)Heartworm Prevention (1 month supply)4DX Heartworm TestWellness Blood PanelFecal TestSpay (Please complete the CPR Consent Form on next page)Neuter (Please complete the CPR Consent Form on next page)Dental (Please complete the CPR Consent Form on next page)Other
For spay patients, please list the date of your pet's last day of their heat cyle. Type N/A for non-spay patients or if your pet has not had their 1st heat cycle.*
Please list additional services Urban Veterinary Associates is authorized to provide:
In the event that additional services are deemed necessary for the patient's care beyond those listed above, I elect the following*

Proceed with necessary treatmentAll additional treatments are the foster's responsibilityCall our rescue organization to approve additional treatments
We understand that if our organization cannot be reached for authorization within a period of 10 minutes, the requested services will be declined, and an additional appointment will need to be scheduled to continue the patient's care.
NOTE FOR FEMALE PATIENTS IN HEAT

For the patient's safety, our doctors recommend spaying your pet 8 weeks after the last day of their heat cycle. If the patient's last day of their heat was not 8 weeks ago, their may be additional costs for their procedure or we may have you reschedule. Please reach out at 630-541-8088 if you have any questions or concerns.
Cancellation/Late Policy
Our goal at Urban Veterinary Associates is to provide the highest quality medical care for your pet. Each appointment is dedicated to each patient to discuss concerns and recommendations. Please provide ample notice if you have to cancel or reschedule. All appointments scheduled Monday-Wednesday & Friday must be cancelled or rescheduled 24 hours prior to the scheduled appointment time. All surgical procedures, Saturday, and drop-off appointments must be cancelled or rescheduled 48 hours prior to scheduled appointment time. This time will be reallocated to someone who is in
urgent need of treatment. Failure to be present at the time of a scheduled appointment or provide fewer than required notice of cancellation will be recorded in the patient’s chart as a "No show" and cancellation fee will be applied to the account.

We make every effort to be on time for all our appointments. Unfortunately, when even one patient arrives late, it can throw off the entire schedule for that day. In addition, rushing or “squeezing in” an appointment shortchanges the patients and contributes to decreased quality of care. If you are more than 10 minutes late to your appointment, a late fee will be applied to your account. If you arrive more than 15 minutes late, your appointment will be rescheduled, and a cancellation fee will be applied to your account. We apologize for any inconvenience this might cause.

Payment information

Payment must be remitted within 14 days after the appointment date for services authorized by the organization. Any additional services not authorized must be paid the day of the appointment. At the end of each appointment, Urban Veterinary Associates will e-mail a finalized invoice to the email provided for your organization.

I acknowlege and understand the above statements.
Signature*
CPR Consent Form for Anesthetic Procedures

Complete this document for all surgical, anesthetic, and inpatient procedures.
I understand that the anesthetic, surgical or therapeutic procedures may involve the risk of complications, injury or even death, from both known and unknown causes and no warranty or guarantee has either been expressed or implied as to the result or cure. Should the patient (listed above) require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency medications, or other heroic interventions, I request that the doctor at*

Conduct CPRNot Conduct CPRPatient is not presented for an anesthetic procedure.
If I request such emergency procedures, I agree to be held responsible for veterinary services provided to the patient while staff members pursue treatment and try to reach me for further directions. Regardless of my pet’s recovery or survival, I agree to pay CPR fees in addition to other fees already identified by the practice and agreed upon by me.I accept that if the hospital staff is unable to reach me within 20 minutes after the initial CPR procedures, and after exercising reasonable medical judgement, determine that there is no hope for success, the staff will cease further CPR procedures. I understand that despite the best effort of the doctor and staff at this facility, even the most successful CPR that my restore my pet’s life may not allow for my pet to regain his/her normal mental and physical heath and, thus, may leave him/her as an invalid. Please sign below. *

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Consent Form for Authorized Treatment

CPR Consent Form for Anesthetic Procedures