Critical Care Authorization Form

Save time getting your pet critical care by completing our authorization form online.

Critical Care Authorization Form

Please complete this form as accurately as possible so we can proceed with your pet’s care.

different Name Emergency

Your pet has been presented in a critical or life-threatening state. In 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 responsibility for the care.

The initial costs of Critical Care stabilization are varied based on pet and condition of the pet. Our staff can provide you with an estimate for the initial stabilization of your pets condition. This estimate is for initial stabilization only and does not include continued care once your pet is stabilizing nor does this estimate include hospitalization, treatments, medications or follow-up care.

A Doctor/Staff member will speak to you as soon as reasonably possible and will provide you with a written estimate of expected charges for continued care at that time. A deposit will be required for patients remaining in the hospital for continued care.

Sign one of the two following agreements: 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, shock treatment/medications, blood laboratory evaluation and/or radiographs.

Contact Name *

First

Last

Contact Phone Number *

Emergency Phone (If different from Contact Phone)

Contact Email Address *

Pet Name (First Name Only) *

Pet Species *

Pet Breed

Today's Date *

Checkboxes *

I authorize immediate Critical Care Treatment and accept financial responsibility.
I do NOT wish to have Critical Care Treatment provided until I have spoken with the doctor and have been provided with an estimate of all expected charges. I understand this may delay critical care treatment that may be necessary to save the life of my pet. 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 Doctors and staff from liability from any complications related to my choice to delay treatment.

Critical Care Authorization Form

Critical Care Authorization Form

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