I hereby authorize the veterinarians, and all of their affiliates, and their respective employees, agents, contractors and representatives (collectively the “Medical Professionals”) to administer treatment as is considered therapeutically and/or diagnostically necessary.
I authorize medical treatment, as well as possible alternative modes of treatment, as explained to me by the Medical Professionals. I further authorize surgical procedures of an emergency nature, if deemed necessary.
I further understand that there is a state licensed professional counselor to provide me with coping, grief and other services relating to my pet’s health care, status and any decisions which I may make or have made in that regard and that she will make an appropriate referral for me should she believe that I may benefit from other counseling services. I further understand that (a) I can refuse this service and (b) I will not be billed should I take advantage of these services.
I give my permission to release case/patient information and/or photos so they may be used in teaching, continuing education, website, veterinary literature, and the like while patient confidentiality will be maintained.
I consent to the release of all of my medical information to Veterinary Specialty Center, Inc., Surgical Referral Service, Ltd., VSC Rehabilitation, LLC, and/or Veterinary Imaging Services, LLC (collectively the “Practices”).
I assume full financial responsibility for all charges incurred for the care and treatment of this patient. Unpaid balances over 30 days will accrue an interest rate charge of 2% per month. I understand that if collection action should become necessary for recovery of any monies due under this contract, I agree to pay any and all collection costs up to 40%, court costs, and reasonable attorney fees.
Information provided by me is solely for the use of the Practices and for any practice which hereafter begins performing veterinary services at the same premises as conducted by the Practices or in conjunction with the Practices.
I certify that I am at least 18 years of age and have the authority to make decisions on behalf of the patient.
