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Animal Specialty & Emergency Center
1535 S. Sepulveda Blvd.
Los Angeles, CA 90025
If your pet is hospitalized longer than 48 hours, a hospital representative will call you with an updated estimate on a daily basis.
Future medical services such as: X-rays, treatments, etc. are NOT included in this estimate. _____________
These are estimated fees. If your pet requires additional testing, care or treatment, we will do our best to contact you before doing so.
Additional costs may include:
hospitalization, X-rays, laboratory tests, feeding tubes, bandage changes, blood transfusions,
oxygen therapy, ultrasound examinations, and other items, depending on the nature of the care.
The additional costs may range from <$100 per 24 hours, to >$500 per 24 hours for critical patients.
Animal Specialty and Emergency Center’s doctors and staff are authorized by me to perform all diagnostic and therapeutic procedures that their judgment may determine to be necessary to properly care for and treat my pet’s medical needs. The preliminary plan for the care of my pet has been discussed with me, and I have been informed of the attendant risks of the proposed plan for the care and treatment of my pet. I understand that no promises or warranty have been made to me as a result or cure from the treatment provided.
The estimate range that is being provided to me is intentionally broad because the actual treatment (including but not limited to, antibiotics, analgesia and post-operative treatment required), varies on a case-by-case, patient-by-patient basis. I understand that the total procedure charge is variable. A deposit of the low end of the estimate is required to proceed with treatment.
By leaving this deposit, I understand that this is NOT the actual total amount due for the procedure, and I agree to be fully
responsible for the final charges based upon the actual procedures performed.
I represent that I own the animal or am authorized to bring this animal to the hospital for whatever treatment deemed necessary, and I agree to be personally liable for all obligations incurred to the hospital, whether I have a legal interest in the animal or not. Further, I agree to hold the hospital harmless from any claims to any third party or entity, arising out of the ownership of the animal.
By executing my signature below, I agree to be fully and legally bound by the foregoing provisions.
THE FINAL BILL IS DUE AT THE TIME OF RELEASE OF THE PATIENT.
I, the undersigned owner or agent of the pet identified above, certify that I am ___ I am not ___ (check one) the rightful owner or authorized agent of the owner, am eighteen years of age or over, and authorize the veterinarians at Animal Specialty and Emergency Center to perform the above procedures. I understand that some risks, including the risk of complications or even death, exists with any anesthetic event or surgical procedure and I have been encouraged to discuss any concerns I have about those risks with the attending veterinarian prior to anesthesia or surgery being initiated.
I understand that in the event of an anesthetic or surgical complication resulting in respiratory or cardiac arrest, cardiopulmonary resuscitation (CPR) will be initiated immediately and I will be contacted by the attending veterinarian.
While I accept that all procedures will be performed to the best of the abilities of the veterinarians and staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I agree to pay a deposit of 100% of the estimated fees, assume financial responsibility for the remaining fees, and provide payment via cash, credit card, Wells-Fargo, or check at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above.
As a courtesy, our client liaison will be contacting you every 24 hours with a financial update. Please indicate the best phone number for reaching you with this information during your pet's stay:
____________________________________________________ Phone Number
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