Owner's Name *

First

Last

Phone *

Email *

Pet's Name *

Authorization to Provide Care *

I, the undersigned, certify that I am the owner, or an authorized agent for the owner, of the pet listed above. I hereby authorize Tell Tail Veterinary Urgent Care, the doctor on duty, and the staff to perform medical services including diagnostics, procedures, treatments, medical care, nursing care, surgical care, emergency care, and/or administration of extra-label medications within accepted veterinary guidelines as deemed advisable and/or necessary for my pet. I also understand that no guarantee of successful treatment can be made.

In case of an emergency and/or prior to additional procedures, you will be contacted by telephone. The phone number(s) where you can be reached TODAY is

Phone *

Phone

Notes about my availability: *

In the event that you are not reachable by phone, you may provide permission as follows: (we will attempt to reach you first) *

I authorize the provided estimate only, and nothing beyond without talking to me
I authorize the provided estimate and basic life-saving measures
I authorize the provided estimate and additional treatment as necessary up to $500
I authorize the provided estimate and additional treatment as necessary without regard to cost

Authorization for Life-Saving Treatments

In the event of a catastrophic emergency, please select what life-saving measures you would like performed. (please select one option below) *

Do Not Resuscitate (DNR) If my pet's heart or breathing stops, I do not want CPR performed. I understand this means my pet will pass away naturally.
CPR If my pet's heart or breathing stops, I authorize CPR, including chest compressions, emergency medications, intubation, oxygen support, and additional treatment based on doctor discretion. * Estimated cost: average $1,000-$3,000

- I understand that if my pet does not respond within a reasonable time, efforts will stop.
- I understand that the chance of successful recovery is not guaranteed, and that efforts may still be unsuccessful.

Authorization and Risk Assessment

Authorization and Risk Assessment *

I understand that Tell Tail Veterinary Urgent Care is not a 24-hour hospital. Should an overnight stay be necessary, direct observation will not be available. If my pet needs observation you will need to transport your pet to a 24-hour emergency hospital.
I understand that the veterinarians and staff of Tell Tail Veterinary Urgent Care will do everything possible to minimize any risks to my pet, but that unforeseeable conditions may occur. I will not hold Tell Tail Veterinary Urgent Care, the veterinarians, or any team member liable for any complications that may arise. No warranty or guarantee has been stated or implied to me as to the results or cure afforded by these treatments or procedures.
I understand that I am assuming full financial responsibility for all services rendered at the time my pet is discharged from the hospital. At a minimum, I am authorizing the fee of an exam at the standard rate.

Signature *

Clear Signature

Today's Date *

Day Stay/Care Consent Form