Estimate for Veterinary Services (Sign Here) - Emergency Pet Clinic of Temecula

Client Name*

First Last

Client Email*

Client Email 2

Client Email 3

Client Phone

Patient Name*

Patient ID*

Treatment Date*

Treatment Time*

:

Charge Nurse*

Type*

ER Exam
Recheck Exam
Continued Care

Diagnostics

Treatments

Hospitalization

Cost Estimate

Low*

High*

Time Estimate

Low*

High*

Interval*

Hours
Days

Behavior

Our veterinary hospital takes pride in its compassionate, professional staff, and we expect mutually respectful relationships with our clients. This is an emotionally charged environment for both our clients and our staff. In an effort to protect our employees from verbal abuse and maintain a valid client/patient/doctor relationship any commentary to suggest our primary directive is monetarily based, substandard or allusion to involving an attorney immediately terminates this trust based relationship.

I have read the "Behavior" policy*

Initial here. This is required.

By initialing the following, I acknowledge and accept the above estimate and policies.

I would like to*

Authorize
Decline

The following ARE NOT INCLUDED IN THIS ESTIMATE: follow-up examinations, bandage changes, additional hospitalization, X-rays, laboratory work, and medication.*

Initial here. This is required.

The above-mentioned estimate IS ONLY AN ESTIMATE FOR SERVICES. While we strive to stay within the estimated fees, unforeseen events and unanticipated complications can occur and may cause your actual bill to exceed this estimate up to 30%. Should this occur, we will do everything we can to contact you and an additional deposit may be taken.*

Initial here. This is required.

I, the undersigned owner or authorized agent of the admitted patient; hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer such treatment as is necessary to perform procedures considered therapeutically and/or diagnostically necessary. I also consent to the administration of such anesthetics as are necessary. I further understand that no guarantee of successful treatment is made, and that the risks and probabilities of complications exist with any surgical or medical treatment. In the event your pet undergoes cardiac/respiratory arrest while in hospital, we will immediately take CPR action unless the DNR option below is initialed. The initial cost for CPR could be up to $400.00 or more, depending on the length of CPR time and drugs administered.*

Initial here. This is required.

CPR Code*

Doctors Decision
CPR
DNR

Doctors Decision = Doctor on duty will make educated decision about resuscitation. CPR = Full resuscitation efforts (does not include invasive CPR). DNR = No resuscitation efforts.

Signature*

I hereby authorize Emergency Pet Clinic of Temecula to perform the procedures listed on this estimate.

Signature Date*

Payment for services is due at the time services are rendered. Our hospital offers senior & military discounts with proper documentation. It is the client’s responsibility to make sure any discount is applied at the time of check out.

Name

This field is for validation purposes and should be left unchanged.

Open 24hrs.
27443 Jefferson Ave.
Temecula, CA

Estimate for Veterinary Services

Please review submitted data then scroll down to initial and sign.

Cost Estimate

Time Estimate

Behavior

By initialing the following, I acknowledge and accept the above estimate and policies.

Call Us Today!

951-695-5044