Emergency permission to treatEmergency Treatment Authorization for emergency treatmentCritical or life threatening stateIn order to prevent incorrect assumptions and miscommunications we required authorization to initiate and/or continue acute care to attempt to stabilize your pet, as well as obtain your acceptance of financial responsibly for the care.Doctor CommunicationThe doctor will speak to you as soon as reasonably possible and will provide you with a treatment plan of the total expected charges, including emergency treatment. Your payment for emergency treatment will be applied to the total costs. A deposit of the treatment plan will be required to continue care. Northeast Veterinary Clinic accepts, Visa, MasterCard, Discover, American Express and Care Credit. Montana Animal Clinic does not have any kind of Payment Plans.Payment for emergency treatment ( Please Select if you are able to make the $300 deposit)* The Initial cost of Critical Care stabilization are Estimated at $300. This estimate is for initial stabilization only and does NOT include continued care Owner's Name:* First Last Phone*Pet's Name:*Date* MM slash DD slash YYYY Please select ONE of the two following agreements:* I am the Owner/Agent for this pet and I am over 18 years of age. I DO 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. I am the Owner/Agent for this pet and I am over 18 years of age. I DO NOT wish to have Critical Care Treatment provided until I have spoken with the doctor and have been provided with a Treatment Plan of all expected estimated charges. I understand this may delay treatment that may be necessary to save the life of my pet. I understand there is a risk of death by delaying treatment. I take full responsibility for delaying care. I assume all risks of delay. Further, I release the Doctor, Northeast Veterinary Clinic and its staff from liability from any complications related to my choice to delay treatment. Electronic Signature: By entering my FULL NAME*I certify that this form has been reviewed by me. I have read it and understood all aspects of this form. I understand and agree to its contents.
