Philadelphia Animal Specialty & Emergency
I affirm that I am over 18 years of age and am the owner or agent responsible for the animal described above and have authority to execute consent.
I authorize and direct the health professionals of this hospital to undertake, initiate and/or administer medical examinations, diagnostic testing, treatments, medications including compounded drugs, anesthesia, procedures, medical electives, medical requirements, hospitalization, home care programs, practices considered 'alternative' or 'integrative' or 'natural', transport, transfer, boarding and/or discharge ("Services") as may be necessary for the purposes of improving the health of my pet. The specific Services I have authorized are outlined on my signed estimate and noted in my client/patient file, copies of which I may request and review at any time. I acknowledge that the nature, purpose and risks of these have been explained to me.
Risks, Adverse Reactions, Refusal To Consent & Indemnification
I understand and acknowledge the following: There are risks involved with any and all Services, as well as to my refusal to consent to Services that medical professionals may recommend ("Refusal"); Risks can include the worsening of my pet's illness or condition, further injury or death ("Risks"); Adverse reactions to Services can result in temporary and/or permanent organ impairment and/or death ("Reactions"); It is my responsibility to call Philadelphia Animal Specialty & Emergency ("Hospital") or the nearest veterinary healthcare facility should my pet experience any Reactions following discharge from this hospital; I have been encouraged to discuss any questions or concerns I have about potential Risks and Reactions with medical professionals of this Hospital before Services are initiated; I maintain full financial, medical and legal responsibility for any outcome that results from my Refusal. I agree to indemnify, hold harmless and defend the veterinarians, staff and Hospital from and against any and all liability relative to any Services, Risks, Reactions and/or my Refusal. I acknowledge that the Hospital is not responsible for clipper burn, minor nicks or skin irritation resulting from surgery preparation.
In the event the medical professionals of this Hospital advise me that the prognosis for my pet is uncertain, I understand that intensive surgery, medical and/or critical care will require considerable time, effort and cost.
Inexact Science/No Guarantee
I accept that veterinary medicine is an inexact science and I acknowledge that no guarantee exists or has been promised to me as to the result or outcome of any Services.
Restraint By Owner
For the safety of individuals or other animals on the premises, I understand that I am not allowed to restrain my pet for the purpose of assisting on any Service at any time. If I choose to insist on restraining my pet, I certify that I have sufficient education, training and experience in animal restraint to restrain my pet.
Fees And Payment
I acknowledge that fees and charges ("Fees") have been thoroughly explained to me, including the purpose of all Fees, nature of all Services, and the value thereof. I agree to pay all such Fees in full at the time of discharge for Services rendered. If my pet is hospitalized, I agree to pay a deposit of 75% of the highest-end of estimated Fee, and assume complete financial responsibility for the balance of Fees at the time of discharge. I agree to pay interest on any unpaid amounts at either 16% annually or the maximum rate allowable by law, whichever is less. I understand that it is my responsibility to call the hospital at least every twenty-four hours to inquire as to the medical status of my pet and the fees incurred for medical services up to that day.
I certify that, unless indicated in the Patient Information section above, to the best of my knowledge my pet has not bitten any person or animal in the last 15 days, and has not been exposed to rabies.
I agree that either I, or an authorized agent on my behalf, will pick up my pet and pay for all accrued Fees upon receiving notification to the contact information maintained in my patient/client file that my pet is ready to be released from the Hospital, unless special accommodations are mutually agreed upon in advance and entered into my patient/client record. I understand that if I fail to comply, the Hospital may handle this abandonment in the best interest of the animal and of the Hospital, in accordance with the law, and I accept that I will be responsible for all Fees incurred for Services and those resulting from my abandonment.
Multimedia And Recording
I authorize the hospital to utilize any multimedia whatsoever regarding my pet for its own purposes in any manner as Hospital may deem appropriate.
I acknowledge that phone conversations to and from the hospitals may be recorded.
Public Statement Correction
If I publicly generate or perpetuate information that, in the sole discretion of Hospital personnel, is factually inaccurate or misleading regarding Hospital or my pet's healthcare at Hospital ("Misinformation"), I authorize and direct Hospital to publicly release and promote relevant information to ensure public correction of such Misinformation.
Referral Veterinarian Commitment
As you are seeing our Emergency or one of our Specialty Services today we maintain a commitment to our referring veterinarians that any new emergency or specialty clients with an existing vet cannot become new general practice clients at Washington Ave. Animal Hospital for a minimum time period of 1 year. This is to maintain a relationship of trust and commitment with our valued referral veterinarians. Please contact us if you have any questions about this policy or special circumstances.
I have fully read this information and understand the contents, implications and purposes thereof. I acknowledge that it is my responsibility to ask questions or raise concerns with the personnel of Hospital, and that my failure to do so does not waive, nullify or alter the Terms stated herein or my responsibilities thereunder. My signature indicates that any questions I have regarding the following issues have been answered to my satisfaction: (A) The reasonable medical and/or surgical treatment options for my pet; (B) Sufficient details of any diagnostic or medical procedures to understand what will be performed; (C) How fully my pet may recover and how long it may take; 101 The most common and serious complications that may result; (E) The length and type of follow-up care and home restraint or care required; (F) The estimate of the fees for all services; (G) Deposit and payment requirements.