Pet's Name*has been admitted to Dulles South Veterinary Center. To more effectively and swiftly assist your pet, we require authorization to initiate and/or continue treatments if needed to stabilize your pet. By signing this form, you are accepting financial responsibility for these treatments, including an emergency exam fee of $99.00. The doctor will speak to you as soon as reasonably possible in a most-to-least critical state order of arrival and will provide you with a medical care plan (an estimate of the total expected charges, including emergency treatments). A deposit of the low end of the estimate is required at this time to continue treatments and will be applied to the total costs. Dulles South Veterinary Center accepts Visa, MasterCard, American Express, Discover, cash, Care Credit and Scratch Pay. WE DO NOT OFFER ANY PAYMENT PLANS.Please select one of the two following agreements* I hereby authorize the veterinarians and staff employed by the partners of Dulles South Veterinary Center (Aldie Veterinary Hospital, LLC and/or Dulles South Animal Emergency & Referral Hospital, LLC) to examine the above animal, stabilize and perform vital diagnostics as necessary for initial stabilization which will not exceed $750, and after consultation with me, to treat, hospitalize, or perform surgery on this animal as outlined in the medical care plan (estimate). I understand that I assume responsibility for the balance of all services rendered. I DO NOT authorize the the veterinarians and staff employed by the partners of Dulles South Veterinary Center (Aldie Veterinary Hospital, LLC and/or Dulles South Animal Emergency & Referral Hospital, LLC) to examine the above animal, stabilize, or perform vital diagnostics until I have spoken with the veterinarian on duty and a medical plan of potential costs is provided. I understand this will delay emergency and potentially life-saving treatments and I assume the risks of this delay. Owner Name* First Last Signature of Owner/Agent*
