Critical Care - Eastside Animal Medical Center

Eastside Animal Medical Center
Financial Authorization for Emergency Stabilization of a Critical Patient
Owner/Agent Name:*
Pet's Name:*
Date:

MonthDayYear
Date
Your pet has been presented in a critical or life threatening state.

The initial costs of Critical Care Stabilization are estimated at $500.

This does not include continued care.

The Doctor will speak with you as soon as reasonably possible.

Your payment for emergency treatment will be applied to the total costs of your pets care. A written estimate of expected costs of continued care will be provided once the initial crisis is under control.

Please sign indicating your understanding of the costs associated with critical care stabilization when your pet is admitted in life threatening crisis:
Yes, I authorize immediate Critical Care Treatment and accept financial responsibility. I am the owner or agent of this pet. I wish to initiate Critical Care Stabilization which can include cardiopulmonary Resuscitation, IV catheter placement, and fluid therapy, pain control, oxygen therapy, or other means deemed necessary by the attending Doctor.
Owner/Agent's Signature:

Clear
OR
No, I do not authorize Critical Care Treatment. I am taking responsibility for delaying the care of my pet and understand that my pet may die without immediate care. I release the Doctor, Eastside Animal Medical Center, PC, and its staff from any liability from complications related to my choice to delay treatment.
Owner/Agent's Signature:

Clear
Should be Empty:

Eastside Animal Medical Center

Financial Authorization for Emergency Stabilization of a Critical Patient