Hyperbaric Oxygen Therapy Authorization Form

Owner

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Patient Name

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Age

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HBOT Session Fees:

1 Session: $122.66

2 Sessions: $245.32

10 Session Package: $1103.98

20 Session Package: $2207.96

Please Initial the Following:

I am either the owner or responsible for said pet and have authority to give this consent. I am at least 18 years of age. I authorize the performance of Hyperbaric Oxygen Therapy as you determine to be indicated. The pet will receive an exam before the HBOT session begins. I agree to indemnify and hold Scottsdale Veterinary Clinic and its employees harmless from and against any and all liability arising out of the performance of any of the procedures referred to here.

I understand that The Scottsdale Veterinary Clinic cannot guarantee a time that my pet will be available for discharge and that TSVC will ensure to communicate with me a time to pick up my pet.

My pet has NOT received a chemo drug called Doxorubicin within the last 7 days. No lotions or perfumes of any kind have been applied to my pet. I have NOT applied any topical flea and tick product to my pet within the last 24 hours.

Phone number where I can be reached today

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Hyperbaric Oxygen Therapy Authorization Form

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