Emergency Treatment Authorization

& CPR Consent

Pet Owner's Name:

Address:

Cell Phone:

Home Phone:

Work Phone:

Email address

I am dropping my pet off for emergency treatment at this location:

39th Avenue/Holistic Location

Newberry Location

Main Street/Downtown Gainesville Location

Springhill Location

Pet Name:

Pet Date of Birth or age, if known:

Pet is a:

Canine

Feline

Pet Breed:

Pet Color/Markings:

Pet Sex:

Male

Female

Unknown

Pet Spayed/Neutered?

Yes

Unknown

Briefly describe symptoms occurring with Pet:

Your pet may have a serious and potentially life threatening injury or illness. Immediate emergency care is required to stabalize your pet. The initial assessment will cost between $250 - $350 for such emergency treatment during the first 30-60 minutes and may include, but not be limited to, medical evaluation, intravenous catheter placement, intravenous fluids, oxygen therapy, pain management, and intensive care/monitoring. If you authorize emergency treatment, we will proceed immediately and you will be responsible for all associated charges. As soon as your pet's condition is stabilized, the doctor will speak with you and prepare a detailed estimate for further care and treatment of your pet. A deposit of 50% of the total estimate will be required at that time.

Please choose one:

I authorize immediate treatment for my pet and understand that I am financially responsible for this treatment.

I do not want any treatments or diagnostics performed on my pet until I speak with the doctor first. I understand that this may delay or prevent potential life saving treatment.

Due to the serious nature of your pet's injury or illness, it is possible that your pet may deteriorate during the course of treatment. Life threatening complications such as respiratory and/or cardiac arrest may occur requiring cardiopulmonary resuscitation (CPR). If your pet stops breathing or his/her heart stops beating, CPR can be initiated but even successful CPR may not restore your pet to good medical and physical health or guarantee successful treatment.

Please choose one:

I authorize CPR in the event my pet stops breathing and/or his/her heart stops beating.

I do not authorize CPR in the event my pet stops breathing and/or his/her heart stops beating. I elect DNR (Do Not Resuscitate).

Signature

Date

Verification