Emergency Vet 98226 - Admission Form

Ownership

Agent

Owner

Name(Required)

First Last

Spouse

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Alternative Phone

Email(Required)

Employer(Required)

Occupation(Required)

Work Phone

Pet's Name(Required)

Color(Required)

Breed/Species(Required)

Age(Required)

Sex(Required)

Spayed/Neutered(Required)

Family Veterinarian(Required)

Car Make/Model

Reason For Visit

Has anyone in the household experienced symptoms or tested positive for COVID-19 in the past 14 days?

Yes

Is your pet current on vaccines (vaccines administered within the past 1-3 years as recommended)?

Yes

Is your pet experiencing any of the following symptoms (check all that apply):*

Is your pet taking any medications (please list)?*(Required)

Does your pet have a chronic medical condition (please list)?(Required)

I authorize licensed veterinarians of Animal Emergency Care (and their designated assistants) to administer such treatment as is needed, surgical procedures as deemed necessary, and such additional procedures as are considered therapeutically and/or diagnostically indicated, on the basis of findings during the course of evaluation. I consent to the administration of necessary anesthetics.

I understand that animals must be picked up between 7:00am and 7:45am if transferring to my home or family veterinarian. I understand that if I fail to pick up my animal by 8:00am, my pet will remain hospitalized. I agree to pay the specified fees for this daytime hospitalization through Boundary Bay Veterinary Specialty Hospital.

I understand and agree that any animal remaining in the hospital without return communication from the listed owner or agent within 12-hours of attempted contact will be considered abandoned and transferred into the care of animal control. It is agreed that such transfer does not relieve me of my responsibility for all costs incurred. I acknowledge that I will be required to contact the animal control office to arrange to be reunited with my pet once this step has been initiated.

I certify that I have read and fully understand the above Authorization of Medical and/or Surgical Treatment. I also certify that no guarantee or assurance has been made as to the outcome of care and treatment. Further, I assume financial responsibility for all charges incurred to the patient, consent to release of medical information, and authorize direct payment to Animal Emergency Care.

Affirm Below(Required)

I have read and fully understand the above Authorization of Medical and/or Surgical Treatment.

Authorization for Transfer of Care between Animal Emergency Care (AEC) and Boundary Bay Veterinary Specialty Hospital USA (BBVSH)

In the event that my pet requires continued hospitalization, I understand that ongoing uninterrupted care will be provided by Boundary Bay Veterinary Specialty Hospital USA from the hours of 9:00am-05:00pm, and conversely by Animal Emergency Care from the hours of 05:00pm-09:00am until which time the patient is discharged or transferred to my family veterinarian.

Should I choose to have my pet transferred to my family veterinarian, I must do so before closing of the aforementioned companies. I understand that the above mentioned companies are housed in the same facility, but that the relationship between these two businesses is not a partnership and that neither company is liable for the actions of the other company.

Transfer Of Care

AEC/BBVSH Transfer of Care (continuous hospitalization without physical patient transfer)

I acknowledge that my pet will remain in the same facility and will receive ongoing uninterrupted care by both Animal Emergency Care and Boundary Bay Veterinary Specialty Hospital. Care provided by each company will be performed by the employees of the respective companies and will be invoiced separately and I am obligated to pay the fees invoiced by each Animal Emergency Care and Boundary Bay Veterinary Specialty Hospital.

Family Veterinarian Transfer of Care (physical transfer to family veterinarian for continued hospitalization)

I acknowledge that my pet will not remain in the same facility, and I will be responsible for transporting my pet to my family veterinarian for continued care. I understand my pet’s medical records will be provided to my family veterinarian who will independently determine the appropriate course of action with regard to my pet’s continued treatment. I understand my pet will need to be discharged between the hours of 7:00am-7:45am

Please select one of the transfer options indicated below. A selection must be made and initialed to complete the transfer of patient care.

Select One(Required)

AEC/BBVSH Transfer of Care

Family Veterinarian Transfer of Care

Acknowledgement of Communication

I understand that I must remain on the premises until my pet has been triaged and a deposit has been collected. I agree to be immediately available by phone and will contact the hospital within 15 minutes of a missed call to prevent delays in treatment to my pet.

I understand that emergency veterinary hospitals are generally operating at capacity and understand that my pet will be triaged and treated primarily based on the critical nature of the condition (stable patients are treated after critical patients) and secondly based on arrival time. I acknowledge that any wait time given by a member of the Animal Emergency Care team cannot be guaranteed due to the nature of cases treated at an emergency veterinary hospital.

Affirm Below(Required)

I have read and fully understand the above Acknowledgement

Authorization of Initial Stabilization Period

I understand that I have the right to accept or deny treatment of my pet in critical condition. These situations do not always allow time for a veterinarian to speak with me prior to intervention. The initial stabilization period if your pet requires immediate treatment can cost $400-600. This may include IV catheters, fluids, medications, x-rays or other tests needed to assess your pet’s condition. The veterinarian will talk to you about further treatment once your pet is more stable if this option is elected. The veterinarian will talk to you about treatment before your pet is stable if this option is declined.

Select One(Required)

Authorize Initial Stabilization ($400-$600)

Decline initial Stabilization Period

Affirm Below(Required)

I have read and fully understand the above authorization

Authorization for Resuscitative Measures (DNR/CPR)

CPR means “Cardiopulmonary Resuscitation” is the resuscitation of an animal that has stopped breathing or has stopped breathing and whose heart is not beating. This condition is called cardio-pulmonary arrest. Resuscitation of an animal that has stopped breathing but still has a heartbeat is more likely to succeed than resuscitation of an animal with no breathing and no heartbeat.

DNR means “Do Not Resuscitate”. This is a decision that states that CPR is not to be performed in the event that your pet stops breathing or has no heartbeat. If you choose DNR and your pet stops breathing or his/her heart stops beating, we will not attempt to revive your pet which will result in the death of your pet.

I the undersigned, do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above and that I do hereby give the doctors of Boundary Bay Veterinary Specialty Hospital USA and Animal Emergency Care, their agents, servants and representatives full and complete authority shall the aforementioned animal go into cardiopulmonary arrest (animal stops breathing and/or heartstops beating) to follow the below requests.

DO NOT RESUSCITATE (DNR):

I DO NOT want cardio-pulmonary resuscitation (CPR) performed on my pet (i.e., NO resuscitative efforts be initiated) in the event of a cardiopulmonary arrest. I understand that my pet will die unless CPR is performed, and that death may occur before I am able to see/say goodbye to my pet. I elect to have DNR orders placed in my pet’s record OR I elect that the veterinary staff stop the initial attempts at CPR that may have been started while I was being informed of the condition of my pet and my options.

STANDARD CARDIO-PULMONARY RESUSCITATION (CPR):

I DO wish the staff to perform Standard CPR on my pet (up to but NOT including open chest procedures) if my pet suffers from cardiopulmonary arrest. Please stop CPR if my pet does not respond to initial attempts or responds initially and then suffers another arrest later. I understand that my pet may die despite CPR or that even the most successful CPR may restore my pet’s life but may not allow my pet to regain his/her normal mental and physical health.

I understand the initial estimate for CPR is $350-600, and the first 24-48 hours of veterinary care after CPR may range from $1500-$3500+ depending partially on the pre-existing injury or illness. I agree to pay all costs incurred in the resuscitative efforts, whether or not the efforts are successful, and I understand that the cost of resuscitative efforts is not included in the initial estimate (treatment plan).

Please select one of the (DNR/CPR) options indicated below. A selection must be made and initialed to ensure the appropriate resuscitation measures are administered.

Select One(Required)

Do Not Resuscitate (DNR)

Standard Cardio-pulmonary Resuscitation (CPR)

Affirm Below(Required)

I have read and fully understand the above authorization

Acknowledgement of Financial Policy

Animal Emergency Care requires payment at time of service and accepts cash, all major credit cards, Care Credit, Scratch Pay, and electronic checks. Electronic checks are authorized by a third-party institution and will require the name, address, phone number, and state identification card information to authorize payment. Electronic checks which are returned for insufficient funds will accrue a $30.00 fee.

Links to the applications for Care Credit and Scratch Pay are provided at:
https://www.animalemergencycare.net/payment-options/

I understand a deposit will be required in the amount of the lowest quote provided on my treatment plan in the event of hospitalization is required including all surgical procedures. I understand Animal Emergency Care and its affiliates will make every attempt to outline the cost of care for my pet. I acknowledge that I have the right to see the treatment plan, with outlined costs, prior to the start of treatment.

I understand I may authorize treatment including verbal authorization in an emergency situation without full knowledge of the respective cost and that anticipated costs are estimates and the care of my animal may be more or less than the anticipated costs. I agree to all fees associated with my pet’s care at the conclusion of treatment.

Animal Emergency Care does not have the ability to offer in-house financing and does not extend credit directly. I agree to neither misrepresent my financial situation nor authorize treatment for my pet which I know I cannot pay at the time of service. I understand financing is available through third party financial institutions and agree to inquire about these financing plans before authorizing treatment which I cannot afford.

I acknowledge my account will accrue financing charges if I do not pay my balance at time of service. I understand my account will accrue five percent (5%) interest, with a minimum fee of $25.00, every thirty (30) days for a sixty (60) day period at which time my account will be placed in collections and pursued to the fullest extent of the law. I agree to be responsible for all costs and attorney’s fees incurred by Animal Emergency Care and/or Boundary Bay Veterinary Specialty Hospital USA to collect amounts owed hereunder.

PAYMENT IN FULL IS REQUIRED AT TIME OF SERVICE. A DEPOSIT WILL BE REQUIRED. ESTIMATED COST OF TREATMENT WILL BE PROVIDED.

I will pay by:(Required)

Signature(Required)