UVH Emergency Consent Form

1
PLEASE INDICATE YOUR DECISION FOR EMERGENCY CARE WHILE THE TEAM AT UVH ARE STABILIZING YOUR PET* This field is required.
YES - I am authorizing emergency veterinary care up to $675. I authorize UVH, its Veterinarians, and team, to examine and initiate life-saving emergency care and treatment for the pet presented. This may include, but not limited to, treatment for shock and pain, oxygen therapy, and initial blood work or radiographs. I understand such treatment is necessary for the purpose of stabilizing the pet to enable a thorough evaluation and to ascertain a course of action.
NO - I do not authorize UVH, to perform any diagnostics/treatment on my pet until the Doctor has spoken to me. I understand that the Veterinarians and team will examine my pet and initiate life-saving measures if necessary.
2
If it becomes necessary during your pet's visit, do you want us to administer CPR?* This field is required.
YES - Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compression, positive pressure respiration, emergency drugs or other heroic interventions, I authorize that the doctors at this hospital provide such medical care and accept responsibility for the related charges.
NO - In the event that my pet's heart and or breathing should stop requiring cardiopulmonary resuscitation (CPR), I decline any and all emergency intervention. Do Not Resuscitate (DNR)
3
Owner Details* This field is required.
First Name
Last Name
Phone
Please enter your email
4
Owner Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Information of person who brought pet in if not the owner
First Name
Last Name
Phone
Please enter your email
6
Date* This field is required.
Date
Year
Month
Day
7
Pet Details* This field is required.
Name
Age
Male
Male Neutered
Female
Female Spayed
Sex
8
University Veterinary Hospital Payment Policy.* This field is required.Estimates are available for all services. Owners are responsible for any charges incurred by their pet while in the care of the doctors at University Veterinary Hospital and charges are due and payable at the time of service. Any balance that is left unpaid will be forwarded to University Veterinary Hospital's collection agency and will incur a delinquent billing service fee of $40 and a possible collection fee for which the owner is liable, in addition to monthly finance charges. University Veterinary Hospital does have a $40 NSF service fee for all returned checks. Clients that have a returned check will lose check writing privileges. We offer estimates for all procedures and reserve the right to require partial payment in advance for the services provided to your pet. Please read all forms and make sure that you understand the forms before signing them. Payment is due at the time of service. Please discuss any financial concerns prior to your pet's care.
9
Signature* This field is required.You agreed to the above and payment is expected at time of service.
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