Patient Name:Elsa ID:861903-1

Client Name:Connie Cooper Date: 2/22/2021

Client Authorization for Care

Surgery Dr. Matthew Barnhart Christina Otani, RVT
1 Department Clinician Technician
Plan: Left TPLO $4200 to $4600
Initial Option A
CBC/Chemistry (within 90 days of surgery) $200 to $200
Initial Option B

2 Department Clinician Technician

Plan: $ to $
Initial Option A
$ to $
Initial Option B
Summary of Client Authorized Care Plan
Total Authorized $ to $

Deposit $2200
*This does not include today's consultation ($178)

Client Rights & Acknowledgements (Please initial numbers 1-4)

1. The Care Plan has been clearly explained to me by a MedVet Doctor or his/her staff. Major risks of any surgery/procedure to be performed
CC have been discussed with me by my MedVet Doctor or a member of his/her staff.

2. I understand that unforeseen complications and/or changes in patient status may occur during the hospital stay or after discharge. These
CC complications or unexpected conditions may alter the Care Plan and will be discussed with me by a MedVet Doctor.

3. Updates on my pet's status and Care Plan will be provided to me following the procedure/surgery, and at least daily by 11:00 AM if inpatient. I
CC will be notified promptly of any significant changes in my pet's condition.

4. In the event of cardiopulmonary arrest or other emergent life threatening situations, I approve the following:

__CC__ I AUTHORIZE MedVet to perform life saving ____I DO NOT authorize MedVet to perform life saving treatments on
treatments on my pet. This may include the administration of my pet. I authorize the attending veterinarian to minimize pain and
medications, chest compressions, oxygen, ventilation, cardiac suffering , and to make attempts to contact and guide me in the
-OR-
defibrillation and other emergency measures deemed management of my pet's care.
medically appropriate. MedVet will make attempts to contact
me in the event of an emergency situation.

The above information was reviewed by phone with _Connie Cooper____ by _Christina Otani, RVT_ on _2/22/21_____ at _12:00PM_
OWNER Signature of DVM/RVT/AA/CSR DATE TIME

Print Name _Christina Otani, RVT

Authorization for care
The above statements have been explained to me and my questions have been answered. To the extent above, I hereby give my consent to the
Doctors and staff on duty to perform authorized diagnostic testing and treatments, including but not limited to, medications, anesthesia and surgery,
as deemed necessary in their best medical judgment. I further consent to the release of medical information regarding my pet to my referring
veterinarian or other agency as deemed necessary by MedVet. I assume responsibility for all charges and understand all balances are to be paid to
MedVet Associates, Inc upon release of my pet. I understand that any balance due after 30 days will have a 2% service charge added monthly. I have
reviewed and understand the information contained on both pages of this form

Owner: Date:

Witness: Date:
 Patient Name:Elsa ID:861903-1

Client Name:Connie Cooper Date: 2/22/2021

Veterinary Staff Visiting and Client Phone Calls

MedVet is a specialty referral and emergency hospital.
As a leader in veterinary medicine, MedVet provides
advanced training for veterinarians through residency
and internship programs. In addition to board certified
specialists, our staff includes residency trained
veterinarians, emergency veterinarians, residents, and
interns. If you have any question about who is
providing care for your pet, please ask one of our
veterinarians.
Visiting is encouraged as a means of aiding your pet's
recovery and your peace of mind. Please schedule a
visit with your MedVet Doctor or his/her staff. If you
choose to call to check on your pet, you will either be
directed to your MedVet Doctor's clinical team or the
nursing team depending on the time of your call. On
occasion, we may need to return your phone call if our
Doctors or staff are busy caring for patients.

Transfers within the Hospital Releases

If you authorize transfer of your pet from the
Emergency Department to a specialty service, a
Doctor of the receiving specialty department will
assume care of your pet and generate a Care Plan for
you to authorize. At that point, a secondary deposit
may be required.
We will make every effort to also keep your
veterinarian informed of our diagnostics and treatment
plans. We recognize that you and your veterinarian are
important parts of your pet's care team.
Patients will be released from the hospital by
appointment. The MedVet Doctor or staff member will
review and discuss the patient release instructions. A
written copy of these instructions will be given to you to
review at home. Releases from the Emergency
Department typically occur in the morning before 8AM.
Releases from a specialty department typically occur
between 11AM and 6PM Monday through Friday, or by
appointment on Saturday, Sunday or holidays. If you
have additional questions after you return home, please
do not hesitate to call.

Special release arrangements may be made to

accommodate out of town or extended work hours.
Please discuss any special time constraints you may
have with your MedVet Doctor or his/her staff.

Personal Items Credit Card Authorization

Please do not leave toys, blankets, leashes, etc. with
your pet, since MedVet cannot ensure their return.
A credit card authorization may be left to cover the cost
of your pet's Care Plan. Payments to MedVet can be
authorized by a telephone call. Please make sure you
have your credit card number, credit card CVV number
and zip code available for verification.

Patient Updates Financing Option

Our Doctors or their staff will contact you daily by Special financing is available through CareCredit®
11:00AM with an update about your pet's condition. If Financing. A deposit may be required until financing has
there is a significant change, you will be contacted by been approved and all required paperwork has been
a MedVet Doctor or staff member as soon as possible. signed.

MedVet - Columbus
300 E. Wilson Bridge Road
Worthington, OH
43085
(614) 846-5800