International Center for Veterinary Services 北京新天地国际动物医院 HOSPITALIZATION AND MEDICAL EMERGENCY AUTHORIZATION 住院及急诊同意授权书
Date: (日期)____________________ Patient file number (病例档案号): P0_________ Client name (print)姓名:__________________________________________________________ I authorize the International Center for Veterinary Services (ICVS) to hospitalize my dog/cat (name)______________,for the agreed treatment from (Dates) ____________________________2006. 我特此授权北京新天地国际动物医院从2006年____月____日起在我的狗/猫（姓名）__________在该医院住院期间进行赡养及治疗。 During this period, should my pet (name) ___________________ require any medical assistance or treatment, I authorize ICVS to conduct all medical treatment including surgery, diagnostics, x-rays and administer anesthesia as required. 在此期间，如果我的宠物（姓名）_________需要任何医疗帮助或治疗，我授权北京新天地国际动物医院ICVS来进行所有的治疗，包括诊断，x光，麻醉和手术等. I agree to pay? ￥ RMB_________ as the deposit for my pet (name)__________(species)___________ for the hospitalization and the treatment. And I accept the total charges that will be incurred, including hospitalization and all treatments. I am fully responsible to pay the total amount when I pick up my pet after release from (ICVS) 北京新天地国际动物医院。In the event of the death of my pet, I request that the remains be ____Held by ICVS and returned to me____Cremated with return of ashes* 我同意支付北京新天地国际动物医院ICVS 为我的宠物进行治疗时所产生的所有费用。同时我同意预支付人民币RMB_____________给北京新天地国际动物医院作为住院押金，待办理出院时支付剩余部分。如果出现了我的宠物死亡的情况，我要求将其遗体： ___ 先由 ICVS保管，之后交还给我 ___ 火化遗体 I authorize and approve in advance cremation costs of RMB 1,000.00 – 1,400.000 in the event that it is required. I understand this is an additional charge and not part of medical treatment expenses that I have also authorized. I will respect and follow the (北京新天地国际动物医院) ICVS ‘s policy for hospital visits. 我授权并且提前同意火化费用在RMB 1,000.00 – 1,400.000 之间（如果有需要的情况下）。我完全理解这是一项额外的费用并不包括在我已经授权的医疗费用里。我将遵守北京新天地国际动物医院的所有规定及探视时间。 1). I authorize ________________as my representative in China to act on my behalf to execute medical decisions related to my pet and to pay the expenses incurred during the hospitalization period and full power to sign any related medical documents in connection with my pet’s healthcare. 1). 我在中国的全权授权委托人将全权代理本人行使一切有关与我宠物相关的权利责任（包括签署所有与宠物医疗相关文本，支付所有产生的相关费用等） Name of Representative全权授权委托人姓名: _______________ 身份证明 ID Number: _____________________ Contact Number:联系电话: ____________________________ 邮箱地址E-mail: __________________________________ Signature签字：_________________________________ 2). My contact information overseas/outside Beijing is:我在国外/北京之外的联系方式： Phone number1电话号码1: ____________________ Phone number2电话号码2: ______________________ E-mail邮箱地址:: _______________________________ Signature签字: _________________________________ 3). My authorized representative overseas in case I cannot be contacted is: 假如无法和我取得联系的话，我在国外的全权授权人为： Name of Representative:全权授权委托人姓名: ________________________ 身份证明 ID Number：_______________________________ Contact Number:联系电话: _________________________ E-mail邮箱地址: __________________________________ Signature签字：___________________________ I am fully responsible for my decision above. 以上均为本人真实意愿; 特此授权 Date日期: __________________________________ Name (print)委托人姓名: _______________________ Signature签名:________________________________

International Center for Veterinary Services

北京新天地国际动物医院

HOSPITALIZATION AND MEDICAL EMERGENCY AUTHORIZATION
住院及急诊同意授权书

Date: (日期)____________________ Patient file number (病例档案号): P0_________
Client name (print)姓名:__________________________________________________________

I authorize the International Center for Veterinary Services (ICVS) to hospitalize my dog/cat (name)______________,for the agreed treatment from (Dates) ____________________________2006.

我特此授权北京新天地国际动物医院从2006年____月____日起在我的狗/猫（姓名）__________在该医院住院期间进行赡养及治疗。

During this period, should my pet (name) ___________________ require any medical assistance or treatment, I authorize ICVS to conduct all medical treatment including surgery, diagnostics, x-rays and administer anesthesia as required.

在此期间，如果我的宠物（姓名）_________需要任何医疗帮助或治疗，我授权北京新天地国际动物医院ICVS来进行所有的治疗，包括诊断，x光，麻醉和手术等.

I agree to pay? ￥ RMB_________ as the deposit for my pet (name)__________(species)___________ for the hospitalization and the treatment. And I accept the total charges that will be incurred, including hospitalization and all treatments. I am fully responsible to pay the total amount when I pick up my pet after release from (ICVS) 北京新天地国际动物医院。In the event of the death of my pet, I request that the remains be
____Held by ICVS and returned to me____Cremated with return of ashes*

我同意支付北京新天地国际动物医院ICVS 为我的宠物进行治疗时所产生的所有费用。同时我同意预支付人民币RMB_____________给北京新天地国际动物医院作为住院押金，待办理出院时支付剩余部分。如果出现了我的宠物死亡的情况，我要求将其遗体：
___ 先由 ICVS保管，之后交还给我 ___ 火化遗体

*I authorize and approve in advance cremation costs of RMB 1,000.00 – 1,400.000 in the event that it is required. I understand this is an additional charge and not part of medical treatment expenses that I have also authorized. I will respect and follow the (北京新天地国际动物医院) ICVS ‘s policy for hospital visits.

*我授权并且提前同意火化费用在RMB 1,000.00 – 1,400.000 之间（如果有需要的情况下）。我完全理解这是一项额外的费用并不包括在我已经授权的医疗费用里。我将遵守北京新天地国际动物医院的所有规定及探视时间。

1). I authorize ________________as my representative in China to act on my behalf to execute medical decisions related to my pet and to pay the expenses incurred during the hospitalization period and full power to sign any related medical documents in connection with my pet’s healthcare.

1). 我在中国的全权授权委托人将全权代理本人行使一切有关与我宠物相关的权利责任（包括签署所有与宠物医疗相关文本，支付所有产生的相关费用等）

Name of Representative全权授权委托人姓名: _______________
身份证明 ID Number: _____________________
Contact Number:联系电话: ____________________________
邮箱地址E-mail: __________________________________
Signature签字：_________________________________

2). My contact information overseas/outside Beijing is:我在国外/北京之外的联系方式：

Phone number1电话号码1: ____________________
Phone number2电话号码2: ______________________
E-mail邮箱地址:: _______________________________
Signature签字: _________________________________

3). My authorized representative overseas in case I cannot be contacted is: 假如无法和我取得联系的话，我在国外的全权授权人为：

Name of Representative:全权授权委托人姓名: ________________________
身份证明 ID Number：_______________________________
Contact Number:联系电话: _________________________
E-mail邮箱地址: __________________________________
Signature签字：___________________________

I am fully responsible for my decision above.
以上均为本人真实意愿; 特此授权

Date日期: __________________________________

Name (print)委托人姓名: _______________________

Signature签名:________________________________