First Name*
Last Name*
Primary Phone*
MobileHomeWork
Allow Text?YesNo
I am the owner or authorized agent for the owner, and I have the authority to execute this authorization.*
I hereby authorize the veterinary team of Animal Cardiology Specialists of Nevada to examine, prescribe for, and treat my pet.*
I understand that I will receive a summary of the care provided in order to ensure that my pet's care can be continued without interruption.*
I also understand that the identification of a referring veterinarian by me to be my authorization for Animal Cardiology Specialists of Nevada to obtain medical records, as well as release records and information to that veterinarian. Case information, medical images, photos and/or videos of my pet(s) may be used in teaching forums, continuing education, hospital web site, veterinary literature, and the like. I authorize the release of case/patient information for such purposes. Patient confidentiality will be maintained.*
I have read and agree to the treatment authorization policy.*
I give my permission for ACSN to use my pet's photo in social media posts.YesNo
Payment is due as services are rendered. The balance will be due upon discharge from the hospital. You may pay by cash, Care Credit, or accepted credit cards.
In order to avoid misunderstandings, please let us know immediately if these terms are not satisfactory. In the event payment is not made at the time of service, it is our policy to apply a service charge to accounts with a balance.
The nature of these procedures and associated costs have been explained to me, and I have been provided the opportunity to have my questions answered.*
Recommendations may change as diagnostics are performed, results and records are received, and/or as my pet's condition changes. Any adjustments to this treatment plan will be discussed with me prior to authorization and implementation.*
I understand that I (the owner or agent) am financially responsible for all charges relating to this patient.*
I have read and accept the financial obligations policy.*
Signature*
Today's Date*
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