Download TREATMENT PLAN

TREATMENT PLAN
VCA Aurora Animal Hospital
2600 West Galena Blvd. | Aurora, IL 60506| (630) 301 - 6100
Hilbert, Julianna DVM | Prepared: 2/3/2016 at 7:36 PM | Treatment Plan: 89464709
Client
Plainfield Small Paws Rescue (#57918)
Sara Pace
12226 Peartree Way
Plainfield, IL 60585
Patient
Colin (#128471)
Species: Canine (Bichon Mix)
Sex: Male Neutered | Color: White
Birth: 01/19/2011 | Age: 5y | Weight:
Detailed Information
Date
Description
Qty
Price
Tax
Total Price
Day 1
Emergency Exam
1
$136.00
$0.00
$136.00
Coagulation Panel
1
$88.10
$0.00
$88.10
VetScan Comprehensive Diagnostic Profile + CBC
1
$204.00
$0.00
$204.00
Urinalysis
1
$72.25
$0.00
$72.25
- US Guided Cystocentesis
1
$28.00
$0.00
$28.00
Thoracic Study
1
$252.30
$0.00
$252.30
- RadiologyInterpretation
1
$78.85
$0.00
$78.85
Emergency Serv/aft hrs OnCall
1
$500.00
$0.00
$500.00
Tech ER Services
2
$200.00
$0.00
$200.00
MRI Other (-C)
1
$859.35
$0.00
$859.35
Imaging Consultation
1
$303.35
$0.00
$303.35
Anesthesia Imaging MRI
1
$230.55
$0.00
$230.55
Fluids Imaging
1
$29.25
$0.00
$29.25
Mechanical Ventilator
1
$64.85
$0.00
$64.85
Fluids Surgery
1
$122.45
$0.00
$122.45
Hemilaminectomy
1 $1,315.62
$0.00
$1,315.62
IV Fluid Maintenance/hr
48
$185.28
$0.00
$185.28
Anesth 1-2.5hr Risk 2
1
$440.15
$0.00
$440.15
Hospitalization Setup
1
$35.10
$0.00
$35.10
72
$701.28
$0.00
$701.28
Cefazolin 100mg/ml/ml
5
$20.65
$0.00
$20.65
Cefazolin 100mg/ml/ml
5
$20.65
$0.00
$20.65
Hospitalization
Thank you for trusting us with your pet’s care. Your friends at VCA Aurora Animal Hospital.
1 of 3
TREATMENT PLAN
VCA Aurora Animal Hospital
2600 West Galena Blvd. | Aurora, IL 60506| (630) 301 - 6100
Hilbert, Julianna DVM | Prepared: 2/3/2016 at 7:36 PM | Treatment Plan: 89464709
Famotidine 10mg/ml/ml
3
$21.49
$0.00
$21.49
Cefazolin 100mg/ml/ml
5
$20.65
$0.00
$20.65
Cefazolin 100mg/ml/ml
5
$20.65
$0.00
$20.65
Infused Medication
2
$96.00
$0.00
$96.00
Bladder Expression
3
$140.70
$0.00
$140.70
Famotidine 10mg/ml/ml
3
$21.49
$0.00
$21.49
MISC Prescription
1
$22.30
$1.84
$24.14
Pain Mgmt Level 2
1
$300.00
$0.00
$300.00
THIS TREATMENT PLAN AND ESTIMATE MAY RANGE FROM: $6,533.15 To $7,513.12
Client’s Initials: _________________
AUTHORIZATION FOR MEDICAL AND/OR SURGICAL TREATMENT
I, the undersigned, certify that I am the owner, or authorized agent for the owner, of the animal, "Colin". I authorize the
doctor on duty and assistants to perform the procedures listed in the above treatment plan and estimate, including
administration of pain relief medications, sedatives and/or anesthetics, as well as any necessary and appropriate
medical, radiological, surgical, diagnostic and/or emergency care for Colin.
I have been advised as to the nature of the procedures and the potential risks, and I understand the reason why such
medical and/or surgical treatment is considered necessary, as well as its advantages, and possible complications, if any. I
also understand that no guarantee of successful treatment can be made.
In some cases it is impossible to accurately estimate the total charges involved because the total extent of the injuries or
illness may not be immediately apparent. The results of blood tests, urinalysis, radiographs, etc. may be needed before
the doctor can approximate a total expense. Additionally, it is impossible to accurately estimate the time an individual
animal needs to respond to a treatment plan and this factor will affect the total cost. It is understood that these are
estimated fees.
If additional treatment is needed that exceeds the estimated range, the hospital will contact me with an updated
treatment plan and estimate to obtain my permission to proceed, and I will increase my deposit accordingly. In the
event that any urgent care requirements arise and the hospital makes a reasonable attempt but is not able to contact
me, I grant permission to render to Colin whatever emergency and life-stabilizing treatments are deemed necessary by
hospital personnel and agree to pay for these emergency and life-stabilizing treatments even if they exceed this
estimate.
Thank you for trusting us with your pet’s care. Your friends at VCA Aurora Animal Hospital.
2 of 3
TREATMENT PLAN
VCA Aurora Animal Hospital
2600 West Galena Blvd. | Aurora, IL 60506| (630) 301 - 6100
Hilbert, Julianna DVM | Prepared: 2/3/2016 at 7:36 PM | Treatment Plan: 89464709
I understand that prices on this treatment plan and estimate are valid for 30 days from the document date. If additional
care is necessary, that exceeds the initial estimate, we will require payment of the current balance in full plus an
additional 50% of the new estimate.
Client's Initials: __________________________
A MINIMUM DEPOSIT OF 50.00% OF THE ESTIMATE IS REQUIRED: $3,266.58
I assume full financial responsibility for all charges and services incurred to Colin while in the hospital and agree to pay
all such charges at the time of release of such patient.
I hereby certify that I have read and fully understand this authorization for medical and/or surgical treatment.
__________________________________
Signature of Owner or Responsible Agent
(Must be over 18 years of age)
____________
Date
__________________________________
Signature of Hospital Employee
When did your pet last eat? __________________________
(Time / Day)
Phone numbers where you can be reached today (Note times if applicable):
Home: ____________________
Work: _______________________
Cell: ______________________ Pager/Other: ____________________
Summary
Patient Name
Total Price
Total Tax
Total Due
Colin
$6,531.31
$1.84
$6,533.15
Previous Balance:
Estimate Total:
Grand Total:
Thank you for trusting us with your pet’s care. Your friends at VCA Aurora Animal Hospital.
3 of 3
-$3,266.58
$6,533.15
$3,266.57