Emergency Authorization / Vacation Form

Date

Name

First NameLast Name

Pet's Name

Pet's Breed, color & age

Phone Number (in case of emergency)

Please enter a valid phone number.Format: (000) 000-0000.

Phone Number (in case of emergency)

Please enter a valid phone number.Format: (000) 000-0000.

Email (in case of emergency)

example@example.com

Dates of travel or expiration date of this form:

Name of Designated Agent or Caregiver:

Phone Number of Designated Agent / Caregiver

Please enter a valid phone number.Format: (000) 000-0000.

Email (Designated Agent / Caregiver)

example@example.com

Relevant medical history:

Other medical concerns:

Please list current medication(s), dose, frequency & route of administration:

I authorize emergency veterinary care costs up to (fill in dollar amount):

I authorize examination, labwork, x-rays and medical emergency treatment recommended by the veterinarian to diagnose and treat my pet, up to the amount listed above.

YesMy designated agent is authorized to make this decision on my behalfDo not perform any diagnostics or treatments on my pet without my direct consent

I authorize emergency surgery on my pet, if deemed necessary by the veterinarian.

YesMy designated agent is authorized to make this decision on my behalfDo not perform emergency surgery on my pet without my direct consent

I authorize humane euthanasia, without my direct consent, if the veterinarian deems it to be in the best interest of my pet.

YesMy designated agent is authorized to make this decision on my behalfDo not euthanize my pet without my direct consent

In the event of my pet's death, I wish the following to be done with his/her remains (choose all that apply):

Private Cremation (ashes returned)Communal Cremation (no ashes returned)Keep remains in the freezer until I returnClay Paw PrintKeepsake print (foam) with Photo Box

I do not authorize the following procedures (please provide a description of what is to be done in place of this procedure/treatment):

Additional notes:

I would like to keep a credit card on file to cover payment for services rendered, not to exceed the amount listed above.

Yes - I will call the clinic and provide the credit card informationMy designated agent will pay the bill upon discharge of my pet, on my behalf

I am the owner of the animal described above. In the event that I cannot be reached, I have indicated my wishes for treatment of my pet or I have given authorization to my designated agent to make decisions on my behalf, up to and including emergency surgery and euthanasia. Where applicable, I have also listed guidelines and limitations of care. I accept financial responsibility for emergency care of my pet.

I agree

Signature