Authorization To Consent To Treatment
Primary Owner:
Primary Owner Name
*
First Name
Last Name
Primary Phone Number:
*
Format: (000) 000-0000.
Email:
*
example@example.com
Secondary Owner:
Secondary Owner Name
First Name
Last Name
Primary Phone Number:
Format: (000) 000-0000.
Pets Authorized For Veterinary Care
Pets Authorized For Veterinary Care:
Rows
Pets Name
Canine/Feline Spayed/Neutered
Breed
Age
Medications
1
2
3
4
Authorized Caregiver(s):
Caregiver 1 Name
*
First Name
Last Name
Primary Phone Number:
*
Format: (000) 000-0000.
Caregiver 2 Name
First Name
Last Name
Primary Phone Number:
Format: (000) 000-0000.
Authorization Window: Start:
*
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Month
-
Day
Year
Date Picker Icon
End:
-
Month
-
Day
Year
Date Picker Icon
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I, the undersigned owner, authorize the above-named caregiver to present my pet for veterinary care in my absence during the dates listed above.
I understand and agree to the following:
The authorized caregiver may approve examinations, diagnostics, and treatments as recommended by the attending veterinarian.
The hospital may make reasonable efforts to contact me for major medical decisions; however, if I am unreachable, I authorize care to proceed as outlined below.
Treatment Limitations
I authorize all necessary care, including emergency treatment
OR
I authorize care up to a maximum of $
Additional instructions or limitations:
I (the owner) accept full financial responsibility for all services rendered.
A valid payment method must be on file or arrangements must be made in advance. Please call our office at (530)272-6651 with payment information.
I understand that veterinary care may involve risks and that the veterinary team will act in the best interest of my pet based on the information available at the time of treatment.
I confirm that all information provided is accurate and that this authorization is valid for the dates listed above.
Owner Signature:
*
Date:
*
-
Month
-
Day
Year
Date
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