TREATMENT PLAN

VCA Animal Specialty Group

4641 Colorado Blvd| Los Angeles, CA 90039| (818) 244 - 7977

Nicole DeNezzo, DVM | Prepared: 3/16/2023 at 19:35 | Treatment Plan: 635167464

Client Patient
Jingwen Hou (#115201) Mei Mei (#144952)
Species: Canine (Maltese)
19535 Nordhoff St 544 Sex: Female Intact | Color:
Northridge, CA 91324 Birth: 10/16/2022 | Age: 21w | Weight:

Detailed Information

Date Description Qty Price Total Low Price

Day 1 Emergency Exam 1 $199.80 $199.80

Hospitalization Setup 1 $71.15 $71.15
Hospitalization/hour 5 $133.35 $133.35
IV Fluids Setup 1 $305.30 $305.30
- Fluids IV Maintenance/hour 5 $42.30 $42.30
Chest Xray Study 1 $505.95 $505.95
- Outside Service Radiology Interpretation NonVCA 1 $144.85 $144.85
Blood Pressure 1 $57.60 $57.60
ESTIMATE Medications 150 $150.00 $150.00
Day 2 Hospitalization/hour 24 $639.13 $639.13
Fluids IV Maintenance/hour 24 $202.66 $202.66
Radiometer Blood Analysis Recheck 1 $30.50 $30.50
- Packed Cell Volume/Total Protein ADD 1 $55.40 $55.40
Neurology InHouse Referral 1 $214.55 $214.55
MRI Brain (+C) 1 $1,800.90 $1,800.90
- Anesthesia Imaging MRI 1 $625.05 $625.05
- Fluids Imaging 1 $156.45 $156.45
- Hospitalization Imaging 1 $228.95 $228.95
Mechanical Ventilation (Anesthesia) 1 $168.95 $168.95
Outside Service Imaging Consult 1 $285.40 $285.40
CSF Tap 1 $582.00 $582.00

For information on how we collect and use information about you and your pet, and how you may opt-out of some uses, please
see our Privacy Policy at vcahospitals.com/privacy-policy.
Thank you for trusting us with your pet’s care. Your friends at VCA Animal Specialty Group.
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 TREATMENT PLAN
VCA Animal Specialty Group
4641 Colorado Blvd| Los Angeles, CA 90039| (818) 244 - 7977

Nicole DeNezzo, DVM | Prepared: 3/16/2023 at 19:35 | Treatment Plan: 635167464

CSF Analysis Cytology 1 $522.90 $522.90

- STAT Charge 1 $163.35 $163.35
Neospora Caninum Antibody by IFA 1 $364.25 $364.25
Fungal Serology Panel 6 1 $967.85 $967.85
Tick Panel 6 w/ Lyme Quant C6 1 $547.35 $547.35
Toxoplasma Split Titer (IgG and IgM) by ELISA 1 $420.15 $420.15
Cryptococcus Antigen by Latex Agg 1 $372.20 $372.20
ESTIMATE Medications 150 $150.00 $150.00
Blood Pressure repeat w/in 24h 1 $45.55 $45.55
Day 3 Hospitalization/hour 20 $532.65 $532.65
Fluids IV Maintenance/hour 20 $168.90 $168.90
Radiometer Blood Analysis Recheck 1 $30.50 $30.50
- Packed Cell Volume/Total Protein ADD 1 $55.40 $55.40
ESTIMATE Medications 150 $150.00 $150.00
Blood Pressure repeat w/in 24h 1 $45.55 $45.55

THIS TREATMENT PLAN AND ESTIMATE MAY RANGE FROM: $11,136.84 to Client
$13,921.05* Initials: [INT*]
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, "Mei Mei". 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 Mei Mei.
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.

For information on how we collect and use information about you and your pet, and how you may opt-out of some uses, please
see our Privacy Policy at vcahospitals.com/privacy-policy.
Thank you for trusting us with your pet’s care. Your friends at VCA Animal Specialty Group.
2 of 4
 TREATMENT PLAN
VCA Animal Specialty Group
4641 Colorado Blvd| Los Angeles, CA 90039| (818) 244 - 7977

Nicole DeNezzo, DVM | Prepared: 3/16/2023 at 19:35 | Treatment Plan: 635167464

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 Mei Mei 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. 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 50.00% of the new estimate.

Client Initials: [INT*]

For hospitals not open 24 hours a day, please be advised that if your pet is hospitalized or otherwise stays overnight or after
hours, there may be periods during which there are no personnel on the premises.

A MINIMUM DEPOSIT OF 50.00% OF THE ESTIMATE IS REQUIRED: $5,568.42

I assume full financial responsibility for all charges and services incurred to Mei Mei 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.

Important Patient/Client Information:

Phone numbers where you can be reached today:

Phone: [____________] Call me [X] Text me [X] Notes: [_______________________________________]

Phone: [____________] Call me [X] Text me [X] Notes: [_______________________________________]

What time did your pet last eat: [_____________________________________________________________________]

Employee notes/comments: [_______________________________________________________________________]

I hereby certify that I have read and fully understand this Treatment Plan Authorization. Signature of Owner or
Responsible Agent Must be 18 years of age or older

Signature: [SIGNATURE*] Print Name: [NAME ]

[____________________________*] [________________*] ]
Date: [DATE

Employee Signature (If applicable below):

Signature: [SIGNATURE] Print Name: [_____________________________] Date: [_________________]

For information on how we collect and use information about you and your pet, and how you may opt-out of some uses, please
see our Privacy Policy at vcahospitals.com/privacy-policy.
Thank you for trusting us with your pet’s care. Your friends at VCA Animal Specialty Group.
3 of 4
 TREATMENT PLAN
VCA Animal Specialty Group
4641 Colorado Blvd| Los Angeles, CA 90039| (818) 244 - 7977

Nicole DeNezzo, DVM | Prepared: 3/16/2023 at 19:35 | Treatment Plan: 635167464

Summary
Patient Name Total Price Total Tax Low Total High Total
Mei Mei $11,136.84 $0.00 $11,136.84 $13,921.05*

Previous Balance: $0.00

Estimate Low Total: $11,136.84
Estimate High Total *: $13,921.05*
Grand Total range: $11,136.84 - $13,921.05*

*APPLICABLE TAXES MAY BE ADDED TO HIGH TOTALS.

For information on how we collect and use information about you and your pet, and how you may opt-out of some uses, please
see our Privacy Policy at vcahospitals.com/privacy-policy.
Thank you for trusting us with your pet’s care. Your friends at VCA Animal Specialty Group.
4 of 4