Authorization for Emergency Treatment

God's Dogs Rescue Veterinary Clinic

Your pet has been presented in a critical or life threatening state. This form is required to authorize emergency care and confirm financial responsibility.

Owner's/Agent's name

Pet's name

Date

Initial Critical Care stabilization costs are estimated at $800. This estimate is for initial stabilization only and does not include continued care, hospitalization, treatments, medications or follow-up care.

PAYMENT FOR EMERGENCY STABILIZATION IS REQUIRED UPON AUTHORIZATION.

We accept Visa, Mastercard, Discover, American Express, cash, CareCredit, and Scratch Pay. We do not accept payment plans or checks.

Treatment authorization choice

I authorize immediate Critical Care Treatment

I do NOT wish to have Critical Care Treatment provided until speaking with the doctor

Authorization for Immediate Treatment: I am the owner or agent for this pet. I wish to initiate or continue Critical Care Treatment, which can include CPR (Cardio Pulmonary Resuscitation), IV catheter placement and fluid therapy, pain control, shock treatment/medications, laboratory evaluation and/or radiographs. I authorize immediate Critical Care Treatment and accept financial responsibility.

Signature for authorization

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Delay of Treatment Acknowledgment: I understand my pet may die without immediate Critical Care Treatment and take responsibility for delaying care. I assume all risks of delay. Further, I release the doctor, God's Dogs Rescue Veterinary Clinic, and its staff from liability from any complications related to my choice to delay treatment.