Treatment Plan Form

By my signature below, I confirm that I am over the age of 18 and am the owner (or authorized representative) of the above described patient, that I authorize Eclipse, Specialty & Emergency Care for Pets and its staff to perform the treatment, and that all my questions regarding the treatment, procedure(s), recovery, side effects and risks involved, use of anesthesia (if applicable),
and estimated fees have been answered. I understand that no guarantee of successful treatment is made.

I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian. I have been advised about the nature of this procedure and understand the risks involved. I also understand that sedation/anesthesia carries its own risks, including death or serious injury, even in apparently healthy animals.

1. Last time patient had food (including treats)
2. Has your pet had any previous reactions to sedation or anesthesia?
Yes   No

If my pet suffers a respiratory or cardiac arrest, I authorize the following resuscitative measures:
I DO wish for my pet to be resuscitated in the event of cardiac or respiratory arrest.    I DO NOT wish for my pet to be resuscitated in the event of cardiac or respiratory arrest.

Please note, your CPR/DNR choice selected on this Estimate will control over any prior CPR/DNR selection you have previously selected.

I understand that the estimate is only an estimate of treatment items and that unforeseen circumstances may alter the final treatment and cost. The estimate is the anticipated high-end and low-end cost of treatment and may not accurately predict the actual treatment costs. If I am unable to be reached and the treating veterinarian determines additional medical treatment is necessary, I authorize the treating veterinarian to provide that treatment and that I will be responsible for all costs. I understand that if costs exceed the treatment plan, I will be responsible to pay for additional amounts not covered by the estimate.

A prepayment equal to the low-end of the estimate is required. Full payment is due at the time the patient is released from the hospital. Late payments are subject to an interest charge of 1.5% per 30 days or less. If the prepayment exceeds the final bill, the balance will be refunded.

Date*

Date

Client Signature*

Client Phone Number*

Please enter a valid phone number.

Client Email*

example@example.com