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contact@telltailvet.com
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Digi-Tail Day Stay/Care Consent Form
Day Stay/Care Consent Form
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Owner's Name
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First
Last
Phone
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Email
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Pet's Name
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Authorization to Provide Care
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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
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Phone
Notes about my availability:
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In the event that you are not reachable by phone, you may provide permission as follows: (we will attempt to reach you first)
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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
An unforeseen medical condition can occur at any time. In the event of a catastrophic emergency, please select what life-saving measures you would like performed. These may include, but are not limited to, IV catheter placement, oxygen support, additional medications, chest compressions, intubation & respiration, or other life-saving measures as indicated. Note, these are at additional cost.
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CPR services up to $1,000
CPR services without regard to cost (over $1,000)
Do NOT perform CPR on my pet
Authorization and Risk Assessment
Authorization and Risk Assessment
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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
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Clear Signature
Today's Date
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