URBANVET

1405 Elliott Avenue West, Suite #100

Seattle, WA  98119

206-352-6900

 

AUTHORIZATION FOR MEDICAL AND/OR SURGICAL TREATMENT

 

I, THE UNDERSIGNED, OWNER OF THE ADMITTED PATIENT, HEREBY AGREE AND AUTHORIZE THE FOLLOWING SURGICAL PROCEDURE(S):

and any additional procedures or treatment as considered therapeutically and/or diagnostically necessary on the basis of findings during the course of said evaluation.  The treatment(s) or procedure(s) is (are) to include whatever is necessary to accomplish the purpose, including but not limited to the administration of drugs and anesthetics.  I, therefore, consent to the administration of such drugs and anesthetics as are necessary.

 

ANESTHETIC RISK:  I understand that all anesthetics present some risk of complications and possible serious damage to vital organs and that in some cases may result in paralysis, cardiac arrest and/or brain damage, or death from known or unknown causes.

 

FINANCIAL RESPONSIBILITY:  I assume full financial responsibility for all charges incurred to the patient, including any additional charges I may incur should my pet be pregnant or obese.  I agree to pay all charges at the time services are rendered.   Should charges not be paid when due, I promise to pay, in addition, all costs of collection and reasonable attorney’s fees, whether or not suit is filed upon.  All delinquent accounts bear interest at the legal rate.

 

“ANY ANIMAL NOT PICKED UP OR SERVICES PAID FOR WITHIN THE TIME REQUIRED SHALL BE DEEMED ABONDONED BY THE OWNER AND WILL BE DISPOSED OF ACCORDING TO SECTIONS 16.54.010 AND 16.4.020 OF THE RCW 1989 REVISED CODE.”

 

I hereby certify that I have read and fully understand the above AUTHORIZATION FOR MEDICAL AND/OR SURGICAL TREATMENT,    the reasons why the above named surgical procedure(s) is (are) considered necessary, it’s advantages and possible complications, if any, as well as possible alternative modes of treatment, all of which can be explained to me by a Doctor if I so request.  I recognize that every conceivable hazard and complication can not practically be mentioned or discussed.  I hereby acknowledge that no guarantees or assurances have been made to me concerning the results of this (these) treatment(s) or surgical procedure(s).  I understand that this agreement shall be effective for any and all subsequent admissions to URBANVET.

 

I have read the foregoing and agree and I herby authorize URBANVET in the manner it routinely follows, to perform the above-mentioned treatment(s) or procedure(s).

I would like a call following the procedure.
I would like a ResQ Microchip International for my pet.

 

Signature of Owner or

Party Assuming Responsibility _____________________________________________  Today’s contact phone # ____________________________________
(Must be 18 years of age)

                                Address __________________________________________________                                         ___________________________________

                                                Street                                                                                                             Apt#

 

                                                                   __________________________________________________

                                                City                                                                 State                                       Zip Code

 

 

Witnessed by _____________________________________________________________________________                               Date __________________________________