Veterinary Treatment Authorization Form

Client Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

In the event that my pet(s) require medical attention while under the care of The Planted RVT LLC, I hereby authorize The Planted RVT LLC to act on my behalf in obtaining veterinary care for and I give permission to the attending veterinarian to administer treatment and/or perform procedures as necessary. I understand that every effort will be made to contact me or my emergency contact prior to The Planted RVT LLC seeking medical attention for my pet(s).

I authorize The Planted RVT LLC to transport my pet(s) to and from the veterinary clinic if needed. I understand that while every effort will be made to ensure the safety, comfort, and well-being of my pet(s), transportation inherently carries certain risks, including but not limited to:
-Accidents or unforeseen events during travel.
-Injury, illness, or escape despite reasonable precautions.
-Stress or anxiety due to travel.

I voluntarily assume all risks associated with pet transportation and agree not to hold The Planted RVT LLC, its employees, or contractors responsible for any injury, illness, loss, or death of my pet(s) except in cases of proven gross negligence or willful misconduct.

I authorize the attending veterinarian to provide The Planted RVT LLC with any medically relevant information regarding my pet(s) health or history.
I understand that I am financially responsible for all veterinary services provided, including emergency care.

I preauthorize veterinary care up to the following amount without any additional approval: $Amount(if left blank, The Planted RVT LLC will attempt to contact you or your emergency contacts prior to any treatment).

Primary Veterinarian Name and Clinic Name*

DVM Name: Clinic Name:

Primary Veterinarian Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Emergency Clinic

Preferred Emergency Veterinarian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Advanced Directives: In the event that my pet experiences a cardiac, respiratory or other life-threatenting emergency that requires resuscitative or other urgent care measures such as CPR, emergency drugs or other similar measures, I request that the veterinarian and/or trained staff pursue such medical care as indicated below:

Resuscitate (R) : I authorize emergency treatment if the situation arises (including cardio pulmonary resuscitation (CPR) and other life-saving treatments) and understand this may result in additional charges. I agree to pay for these emergency and life-stabilizing treatments even if they exceed any estimate I may have been provided by the veterinarian.

Do No Resuscitate (DNR): I do NOT authorize emergency treatment if the situation arises (including CPR and other life-saving treatments) and prefer to be contacted before any additional treatment is performed

CPR or DNR?

CPRDNR

Insurance Notice:

The Planted RVT LLC is fully insured for liability and pet care services through PCI Insurance. Insurance coverage is subject to the terms, conditions, and limitations of the policy.

At The Planted RVT LLC, your pet’s safety is always our top priority during transport. As a licensed and insured Registered Veterinary Technician, in the event of an emergency, my medical training allows me to respond quickly and appropriately, giving you peace of mind knowing your pet is in capable, caring hands from pick-up to drop-off.

By signing below, I release and hold harmless The Planted RVT LLC, its employees, contractors, and affiliates from any and all liability, claims, demands, or actions arising out of or related to the transportation of my pet(s), except where prohibited by law.

Signature*

Current Pets (Name/Breed/Age/Sex)*