Thrive Pet Healthcare Urgent Care Torrance - Treatment Plan Authorization Form

Owner's Name*

First NameLast Name

Email*

example@example.com

Pet's Name*

Dollar Amount of approved items on the estimate*

Please let us know if there are any items on the estimate that you decline*

Date of Treatment Plan*

Date

I understand that the estimate is based on the entering examination of my pet and that it may change as further diagnostic and therapeutic procedures dictate. The estimated range is intentionally broad to anticipate problems and unforeseen factors that can occur in any medical patient.
I understand that this is only an estimate and that the final charges are based on actual procedures performed.
I agree to be responsible for all charges relating to my pet's medical care at the completion of services.
I agree to pay the balance of all charges in full at the end of hospitalization. I also understand that all charges not paid at the time of service are subject to interest, (1.5% per month), collection, and legal fees.
If anesthesia, sedation, or a procedure is planned, I hereby acknowledge that the risks inherent to such procedures have been explained to me.
I understand that any aftercare (including recheck exams, follow up diagnostics, bandage changes, etc...) and medications to be dispensed at discharge are not included in the estimate.
This estimate is valid for 30 days from the above date.

I understand the terms above and authorize services based upon the treatment plan:*

Anesthesia and Advanced Directive

Anesthesia and/or sedation is required for all surgical and some medical procedures. Thrive Urgent Care will recommend preliminary diagnostic tests performed prior to anesthesia. This may include, but is not limited to, bloodwork, x-rays or ultrasounds. You will be instructed as to what tests may be necessary for your pet. Our goal at Thrive Urgent Care is that every patient is treated with the safest patient treatment plan recommended by our professional team. Please ask questions and express any concerns with our team regarding your pet's risk factors prior to any procedure.

I understand that during the performance of the forgoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitates an extension of the forgoing procedure(s) or operation(s) or different procedure(s) or operation(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedures(s) or operation(s) as are necessary and described in the exercise of the veterinarian's professional judgment.

I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.

I know that any time anesthesia, surgery, or medical treatment is performed on any pet, there is a risk of injury or death of the pet. Knowing such risk, I hereby give permission for performance of procedure(s) on my pet, as stated above.

I have been advised as to the nature of the procedure or operations and the risks involved. I realize that results cannot be guaranteed.

I have read and understand the terms above and authorize anesthesia/sedation if it has been recommended.*

All patients being treated at Thrive Urgent Care are required to have an advanced directive in the form of a (CPR) Cardiopulmonary Resuscitation or (DNR) Do Not Resuscitate code. CPR is the resuscitation of an animal that has stopped breathing or whose heart has stopped. Please select an Advanced Directive option*

CPR - I request CPR (Resuscitation) on my pet in the event my pet suffers from a cardiac or respiratory event. I understand that CPR does not guarantee that my pet will have a favorable outcome. Further, I understand that there are fees associated with CPR that could range from $600-800 while the hospital is making every effort to contact me.Do Not Resuscitate - I DO NOT want CPR performed on my pet. I have elected to have a DNR (Do Not Resuscitate) order placed on my pet's record. I understand that my pet will pas away in the event that breathing stops and the heart stops beating.

I am the owner or responsible agent for the animal described above and I have the authority to provide this advanced directive. I am over 18 years of age.

Signature*