WAIVER (Bellingham)

Health Check

During the COVID-19 outbreak, the health and safety of our clients, patients, employees, doctors and our community is paramount.
Have you travelled to any countries outside the United States (including Canada) within the last 14 days?*

YesNo
Did you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill (cough, fever, sneezing, or sore throat) within the last 14 days?*

YesNo
Did you have close contact with a person who travelled outside of the United States in the last 14 days who has become ill (cough, fever, sneezing, or sore throat)?*

YesNo
Have you or anybody in your home had contact with someone who is being tested for COVID-19 or who has been diagnosed with COVID-19*

YesNo

Waivers

Please carefully read and sign the following using your finger or a mouse. Please note: You must be 18 years of age to sign the following waiver.
Your name*

First NameLast Name
Secondary Contact Name
If relevant, list other caregiver, spouse, partner, relative, etc.
Are you a returning client?*

YesNo
Sign to attest you are 18 years of age or over*

Clear
Which phone number should be used for contact today?*
Please enter a valid phone number.
Has any of your personal information changed?*

NoAddressPhone NumberEmailMore than one
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number #1*
Please enter a valid phone number.
Phone Number #2
Please enter a valid phone number.
Email*
example@example.com
Do you have pet insurance?

YesNo
What pet insurance do you have?
What is the policy number?

Your pet's name?*
Has this pet seen us before?*

YesNo
Your pet's breed*
Your pet's sex*

FemaleMaleUnknown
Has your pet been neutered or spayed?*

YesNoUnknown
How old is your pet?*

MonthDayYear
Date
Who is your regular veterinarian?*
Please write the name of the clinic. If your pet does not have a regular veterinarian, please write N/A.
Which veterinarians has your pet seen in the last 6 months?*
Please write the name of the clinics. If your pet has not seen a veterinarian recently, please write N/A.

What it means to authorize treatment

I hereby authorize Boundary Bay Veterinary Specialty Hospital USA to perform the preliminary diagnostic and therapeutic plans that will be discussed with me, along with the attendant risks and costs. I understand that no guarantee can be made as to result or cure. I understand that any procedure/treatment poses a risk to the aforementioned animal, regardless of health status. In the event I cannot be reached, I authorize the doctors and staff to perform any procedures necessary for my pet’s wellbeing and accept all charges that are incurred as a result of such action. I authorize Boundary Bay Veterinary Specialty Hospital USA to release my pet to Whatcom Humane Society in the event I abandon my pet and cannot be contacted for a period of 5 days. Any further action, legal or otherwise, will be carried out by the Whatcom Humane Society.
Sign to authorize treatment*

Full signature goes here Clear

Immediate Treatment

If your pet is in critical condition and in need of immediate treatment, the initial stabilization period can cost around $400 - $600. This may include IV catheters, fluids, medications, x-rays or other tests needed to assess your pet's condition. The doctor will talk to you about further treatment once your pet is more stable. If your pet is stable but would benefit from immediate treatment, such as medication to control pain or to induce vomiting, the initial costs can range from $175 to $300.
Authorization for Immediate Treatment*

YES, I authorize the team to perform the needed emergency care with the estimated cost ranging from $400 to $600.YES, I authorize the team to perform limited immediate treatment with the estimated cost ranging from $175 to $300.NO, I do not authorize such care and need to speak with the doctor before treatment is performed, I understand that the delay in treatment may further endanger my pet's life.
Sign to confirm your immediate treatment selection*

Clear

Authorization for Resuscitative Measures (DNR/CPR)

CPR means “Cardiopulmonary Resuscitation” is the resuscitation of an animal that has stopped breathing or has stopped breathing and whose heart is not beating. This condition is called cardio-pulmonary arrest. Resuscitation of an animal that has stopped breathing but still has a heartbeat is more likely to succeed than resuscitation of an animal with no breathing and no heartbeat.

DNR means “Do Not Resuscitate”. This is a decision that states that CPR is not to be performed in the event that your pet stops breathing or has no heartbeat. If you choose DNR and your pet stops breathing or his/her heart stops beating we will not attempt to revive your pet which will result in the death of your pet.

I the undersigned, do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above and that I do hereby give the doctors of Boundary Bay Veterinary Specialty Hospital USA and Animal Emergency Care, their agents, servants and representatives full and complete authority shall the aforementioned animal go into cardiopulmonary arrest (animal stops breathing and/or heart stops beating) to follow the below requests.
- DO NOT RESUSCITATE (DNR): I DO NOT want cardio-pulmonary resuscitation (CPR) performed on my pet (i.e. NO resuscitative efforts be initiated) in the event of a cardiopulmonary arrest. I understand that my pet will die unless CPR is performed and that death may occur before I am able to see/say goodbye to my pet. I elect to have DNR orders placed in my pet’s record OR I elect that the veterinary staff stop the initial attempts at CPR that may have been started while I was being informed of the condition of my pet and my options.
- STANDARD CARDIO-PULMONARY RESUSCITATION (CPR): I wish the staff to perform Standard CPR on my pet (up to but NOT including open chest procedures) if my pet suffers from cardiopulmonary arrest. Please stop CPR if my pet does not respond to initial attempts or responds initially and then suffers another arrest later. I understand that my pet may die despite CPR or that even the most successful CPR may restore my pet's life but may not allow my pet to regain his/her normal mental and physical health.
I understand the initial estimate for CPR is $400-$600, and the first 24-48 hours of veterinary care after CPR may range from $1500-$3500+ depending partially on the pre-existing injury or illness. I agree to pay all costs incurred in the resuscitative efforts, whether or not the efforts are successful, and I understand that the cost of resuscitative efforts is not included in the initial estimate (treatment plan).
Please select one of the (DNR/CPR) options indicated below. A selection must be made and initialed to ensure the appropriate resuscitation measures are administered.*

DNR (Do Not Resuscitate)CPR (Cardiopulmonary Resuscitation) Estimated cost $400 to $600 with hospitalization post events ranging from $1500 to $3500+
Sign to confirm your resuscitation selection*

Full signature goes here Clear

Authorization for Transfer of Care

Between Animal Emergency Care (AEC) and Boundary Bay Veterinary Specialty Hospital USA (BBVSH)

In the event that my pet requires continued hospitalization, I understand that ongoing uninterrupted care will be provided by Boundary Bay Veterinary Specialty Hospital USA from the hours of 9:00am-05:00pm, and conversely by Animal Emergency Care from the hours of 05:00pm-09:00am until which time the patient is discharged or transferred to my family veterinarian.

Should I choose to have my pet transferred to my family veterinarian, I must do so before closing of the aforementioned companies. I understand that the above mentioned companies are housed in the same facility, but that the relationship between these two businesses is not a partnership and that neither company is liable for the actions of the other company.
- AEC / BBVSH Transfer of Care (continuous hospitalization without patient transfer)
I acknowledge that my pet will remain in the same facility and will receive ongoing uninterrupted care by both Animal Emergency Care and Boundary Bay Veterinary Specialty Hospital. Care provided by each company will be performed by the employees of the respective companies and will be invoiced separately.
- Family Veterinarian Transfer of Care
I acknowledge that my pet will not remain in the same facility, and I will be responsible for transporting my pet to my family veterinarian for continued care. I understand my pet’s medical records will be provided to my family veterinarian who will independently determine the appropriate course of action with regard to my pet’s continued treatment. I understand my pet will need to be discharged before 6:00pm.
PLEASE NOTE: SURGERY PATIENTS

All specialty surgery procedure patients will transfer to AEC for overnight care (we do not discharge to your family veterinarian).
Please select one of the transfer options indicated below. A selection must be made and initialed to complete the transfer of patient care:*

AEC / BBVSH Transfer of CareFamily Veterinarian Transfer of CareI need more information
Sign to authorize your selection of transfer of care*

Full signature goes here Clear

Acknowledgement of Financial Policy

Boundary Bay Veterinary Specialty Hospital requires payment at time of service and accepts cash, all major credit cards, Care Credit and Scratch Pay.

I understand that Boundary Bay Veterinary Specialty Hospital and its affiliates will prepare an estimate based upon the initial examination of my pet. The estimate may change as further diagnostic and therapeutic procedures dictate. I understand that this is an estimate and the final charges are based on procedures performed. The initial estimate is based on our preliminary examination. Final fees may vary considerably from this estimate. I understand that every effort will be made to keep me informed of the current status of my bill throughout my pet’s hospitalization. I acknowledge that I have the right to see the treatment plan, with outlined costs, prior to the start of treatment.

I understand that an initial deposit will be required and agree to pay 100% of the low-end of the estimated cost at the time of admission. I agree to provide a deposit for each additional 24 hours of hospitalization or additional care and procedures needed.

I understand I may authorize treatment including verbal authorization in an emergency situation without full knowledge of the respective cost. I assume financial responsibility for all charges incurred to my pet. I agree to pay the balance of all charges in full at time of discharge. I understand that no guarantee of successful treatment is made.

Boundary Bay Veterinary Specialty Hospital does not have the ability to offer in-house financing and does not extend credit directly. I agree to neither misrepresent my financial situation nor authorize treatment for my pet which I know I cannot pay at the time of service. I understand financing is available through third party financial institutions and agree to inquire about these financing plans before authorizing treatment which I cannot afford.

I acknowledge my account will accrue financing charges if I misrepresent my financial situation and do not pay my balance at time of service. I understand my account will accrue one and a half percent (1.5%) interest, every thirty (30) days for a one hundred eighty (180) day period at which time my account will be placed in collections and pursued to the fullest extent of the law. Should it become necessary to bring collection proceedings against me, I agree to pay, not only the past due balance, reasonable and customary expenses incurred in the collection process, including but not limited to, collection agency fees, attorney fees as awarded by the court, and court costs.

PAYMENT IN FULL IS REQUIRED AT TIME OF SERVICE. A DEPOSIT WILL BE REQUIRED. ESTIMATED COST OF TREATMENT WILL BE PROVIDED.
I will pay by:*

CashCredit/Debit CardCareCreditScratchPay
Signature of Owner or Responsible Agent to acknowledge financial policy*

Full signature goes here Clear

Code of Conduct

Boundary Bay Veterinary Specialty Hospital values your business and are honored you’ve entrusted us with your pet’s care. We will treat you with compassion and respect when you come through our doors and ask the same of you. Abusive language, behavior, and lack of respect toward any of our staff members will not be tolerated. Diagnostic workups and treatment plans are services we provide with the goal of reaching a diagnosis and having a favorable outcome for you and your pet. Unfortunately, not all diagnostics uncover an answer and not all outcomes are favorable; this is due to the nature of disease. While these services are performed with the intent to provide a diagnosis and help your pet through their illness or emergency it is important you understand it is the services provided you are paying for, not the outcome. Emergency service wait times may be long due to continued COVID related developments and country-wide veterinary labor shortage. We operate the emergency service on a triage basis; the most critically ill patients will be seen first. Your pet will be triaged to assess how critically ill they are, and the most critically ill patients will be seen first. If you are experiencing a long wait time, be thankful that your pet is stable enough to wait. Mutual trust and respect are the heart of a good veterinary, client, and patient relationship. Please trust that we are guided by what is in your pets best interest.
Sign to acknowledge the code of conduct*

Full signature goes here Clear

Media Permission

With your consent, we'd love to possibly share your pet's journey in our hospital
Media Permission

Boundary Bay Veterinary Specialty Hospital's doctors and staff believe that "moments matter" and we love to be able to share wonderful moments with pet photos, videos and interesting stories on our social media pages (i.e.: Facebook, Instagram) and website. However, we cannot do it alone! Will you help us by granting permission to use photos/videos of your pet(s) and his or her story?
Do you consent to media permission?

YesNo
Signature of Owner *

Full signature goes here Clear
Are you on Instagram?
How did you hear about us?*
Please provide further details.
For Internet Search please provide the words used when searching
Should be Empty:

Health Check

Waivers

What it means to authorize treatment

Immediate Treatment

Authorization for Resuscitative Measures (DNR/CPR)

Authorization for Transfer of Care

Between Animal Emergency Care (AEC) and Boundary Bay Veterinary Specialty Hospital USA (BBVSH)

AEC / BBVSH Transfer of Care (continuous hospitalization without patient transfer)

Family Veterinarian Transfer of Care

PLEASE NOTE: SURGERY PATIENTS

Acknowledgement of Financial Policy

Code of Conduct

Media Permission

Media Permission