I am the owner, authorized agent for the owner, or a Good Samaritan responsible for seeking
veterinary care for the animal described above, and I have the authority to execute this consent.
My signature below certifies that I am over eighteen years of age.
I have been informed that there are certain risks and potential complications associated with
sedation, anesthesia and/or any operation/procedure/treatment/medication that may result in
injury, harm or even death from both known and unknown causes. These risks and potential
complications have been explained to me to my satisfaction. I further understand that during the
course of the operation(s) or procedure(s), unforeseen conditions may arise that may require the
performance of additional urgent care services deemed necessary by the attending veterinarian. I
am encouraged to discuss any concerns I have about these risks with the attending veterinarian
before the procedure is initiated.
I authorize the use of appropriate anesthesia/sedation, hospitalization, diagnostic testing, patient
monitoring, treatments and medications as needed before, during or after the procedure.
I understand that a treatment plan providing the details and costs for the anticipated veterinary
services will be provided to me, and that I am encouraged to discuss all fees attendant to such
care before services are rendered and during my pet’s ongoing medical treatment. In the event
that hospitalization is required for more than twenty-four hours for ongoing care, I may be
required to pay a deposit of 50% of the estimated fees and assume financial responsibility for the
balance of all services rendered on a cash, credit card or check basis at the time the pet is
discharged from the hospital or the case is otherwise concluded. I understand it is my
responsibility to call the hospital at least every twenty-four hours during the duration of
hospitalization to inquire as to the medical status of my pet and the fees incurred for medical
services up to that day. I understand that veterinary care during nighttime hours and/or
weekends is provided at the discretion of the attending veterinarian, and that if required,
additional charges may apply. Continuous presence of personnel may not be provided during
these hours.
I further agree, that either I, or an authorized agent of mine will promptly pick-up and pay for all
accrued charges when I have been notified that my pet is ready to be released from the hospital.
I agree that if I fail to comply with this policy within five days of oral or written notification of
the readiness to be released, that Companion Skokie may handle this abandonment in the best
interests of the pet and/or the hospital in accordance with the local laws and I will still be
responsible for all fees incurred.
The nature of these operation(s) and/or procedure(s) has been explained to me to my satisfaction
and I understand what will be done. I am aware that the practice of veterinary medicine is not an
exact science and I understand that no warranty or guarantee has been either expressed or
implied as to a cure or a specific result. I have been encouraged and given the opportunity to
discuss any questions I may have regarding my pet’s medical care and my questions have been
answered to my satisfaction. I accept that my financial obligations remain regardless of the
outcome.
I have read and understand this authorization and hereby accept and agree to the terms of the
consent for treatment.
