Agent Authorization Form

Agent Authorization Form

Permission for individual (s) not listed as owner.
Owner's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Permitted Agent or Co-owner (The designated agent must be 18 years of age or older.)

First NameLast Name
Adress of Permitted Agent or Co-owner

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Permitted Agent or Co-owner
Please enter a valid phone number.Format: (000) 000-0000.
Permissions
Start Date as Agent

MonthDayYear
Date
End Date as Agent

MonthDayYear
Date
This person has my permission to approve care up to but not to exceed $amount* without contacting me.
In the event of a severe, life-threatening medical emergency where euthanasia is deemed medically appropriate by the attending veterinarian and I am unreachable:
Should be Empty: