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Emergency Disclosure Form

Emergency Lifesaving Disclosure Form

Your pet has a life-threatening condition and immediate medical treatment is necessary to sustain life or to alleviate or end suffering.
Texas Law HB 4069 (and TBVME Rule 573.83) requires all veterinarians to provide a cost estimate for an emergency exam, stabilizing services, diagnostics, and treatment plan descriptions of recommendations to you for you to authorize prior to performing any lifesaving treatment.
CFVC Statement A Country Friends Veterinary Clinic (CFVC) doctor recommends assessing the immediate needs of your pet by performing an emergency examination and possibly emergency lifesaving stabilization. lt is possible that medical information obtained in the exam may prompt discussion of the choice to alleviate pain/suffering by electing humane euthanasia. Your veterinarian will provide updates regarding your pet's prognosis/treatment as more information becomes available.

Emergency Exam and possible stabilization Fee Information: These are the Initial potential costs to give our staff a chance to assess prognosis and potential treatment. The exam and diagnostics performed may change the treatment costs going forward. As information becomes available, CFVC will update you on the treatment plan and costs. This is an emergency situation, and other diagnostics/treatments may be recommended or some of the treatments below may not be needed. A CFVC doctor will determine best course for your pet. As soon as your pet is stable and the exam has been performed a staff member will update you. By law failure to initial/sign will be interpreted as declining all recommended services.
PLEASE SELECT YES OR NO FOR EACH OF THE FOLLOWING POTENTIAL CHARGES ALLOWING CFVC TO PROCEED IN PROVIDING MEDICAL CARE.
Emergency Exam - $125(Required)
CPR - Cardiopulmonary Resuscitation - $250(Required)
IV catheter placement and Fluid therapy - $180(Required)
Pain Control - $50(Required)
Oxygen Therapy - $100(Required)
Radiographs - $260(Required)
Blood Work - $200(Required)
Texas law HB 4069 states that you, the caretaker of the presented patient have the responsibility to decline or authorize any or all stabilizing options that are expressly indicated by providing your signature on this Emergency Lifesaving Disclosure Form. By law, failure to sign will be interpreted as declining all recommended services.
Caretaker Statement

I have read, understand, and have given my authorization to CFVC's treatment team to perform the treatments selected above. I willingly consent to the information provided to me in this disclosure with full acknowledgement that it is my responsibility to pay the fees of the services elected at the time of service.

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