Owner's Name *

First

Last

Phone *

Email *

Pet's Name *

Authorization to Emergency 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 Moonlight Veterinary Center, 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.

Emergency care may include:

Oxygen support
IV catheter placement
Injections for pain, diuretic, or other stabilizing medications
Diagnostics such as ultrasound or blood testing
Aspiration of fluid from the chest or abdomen
CPR including chest compressions, intubation, and respiration

A staff member will provide you with updates as soon and as often as is reasonably possible. A doctor will speak with you as soon as they are able.

I, the undersigned, certify that I am the owner, or an authorized agent for the owner, of the pet listed above. I hereby authorize Moonlight Veterinary Center, 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. Emergency care may include: ● Oxygen support ● IV catheter placement ● Injections for pain, diuretic, or other stabilizing medications ● Diagnostics such as ultrasound or blood testing ● Aspiration of fluid from the chest or abdomen ● CPR including chest compressions, intubation, and respiration ● Or other as indicated A staff member will provide you with updates as soon and as often as is reasonably possible. A doctor will speak with you as soon as they are able. *

I have read, understand, and agree

In a critical emergency, you may pre-authorize treatment for your pet: *

I authorize an exam and no further treatment
I authorize an exam and additional treatment as necessary up to $500
I authorize an exam and additional treatment as necessary up to $1,000
I authorize an exam and additional treatment as necessary up to $1,500
I authorize an exam and additional treatment as necessary without regard to cost

*Please note a deposit will be taken for the pre-authorized amount/exam

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 Moonlight Veterinary Center 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 Moonlight Veterinary Center will do everything possible to minimize any risks to my pet, but that unforeseeable conditions may occur. I will not hold Moonlight Veterinary Center, 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 *

Emergency Care Consent Form