Veterinary Authorization Form

Pongo's Pals Pet Services

Emergency Veterinary Care Authorization Form
*

First Name Last Name
To the veterinarians at (Animal Hospital and or Vet): *
I give total responsibility for the care of my pets To: Kelly Andrade of Pongo’s Pals Pet Services Contact number: 401.226.2306 When I cannot be contacted immediately, this person will make all decisions regarding necessary treatment in the event of a medical emergency. Pet Name(s):
I wish no more than (see below) to be spent on any one pet. *
I do not want treatment to proceed if there will be permanent disabilities such as: (consider head injuries, loss of bowel or bladder control, loss of a limb, blindness) *
If any of my pets are diagnosed with a terminal condition and their quality of life is impaired, this caregiver has full authority to request euthanasia.
If any of my pets dies suddenly, I Do/Do Not (circle one) want a post mortem performed to determine the cause of death. In the event of a death, it is my wish: *

To have a communal cremation done To have a private cremation done I DO want a post mortem performed to determine the cause of death I DO NOT want a post mortem performed to determine the cause of death
This form was prepared by: *

First Name Last Name
Date *

Month Day Year Hour Minutes AM/PM Option
Please use your mouse or finger to sign this document electronically.
Signature of person preparing form: *

Clear
Should be Empty:

Pongo's Pals Pet Services