AUTHORIZATION FOR MEDICAL AND/OR SURGICAL TREATMENT
(Must be 18 years of age to authorize)
I hereby authorize the doctor on duty (and assistants the doctor may designate) to administer treatment and medication as is considered therapeutically or diagnostically necessary or appropriate on the basis of findings during the course of evaluation of the above-described animal. I also consent to the administration of such anesthetics and surgery as they are necessary or appropriate under the circumstances. I also consent to the release of medical information. I will arrange for follow-up care as instructed.
I HEREBY CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE AUTHORIZATION AND THAT I FULLY UNDERSTAND AND AGREE WITH THE REASONS FOR SUCH TREATMENT, MEDICATION OR SURGERY, ITS ADVANTAGES AND POSSIBLE COMPLICATION (IF ANY), AS WELL AS POSSIBLE ALTERNATIVE MODES OF TREATMENT, ALL OF WHICH HAVE BEEN EXPLAINED TO ME BY THE DOCTOR OR DESIGNATED ASSISTANT.
I ASSUME FINANCIAL RESPONSIBILITY FOR ALL CHARGES INCURRED TO THE PATIENT, and authorize direct payment to South Atlanta Veterinary Emergency and Specialty Center. South Atlanta Veterinary Emergency and Specialty Center will occasionally record photos, video, and/or audio to publish on various media sites (Facebook, SAVES Center’s website or printed materials, etc.) for the purpose of education, marketing or publicity. Please accept or decline the release of your pet’s likeness below by initialing your preference: