Pet Care Authorization Form

Pet Care Authorization Form

If you are unable to bring your pet to their appointment, please complete this form before your visit. It allows the adult you designate to bring your pet to Southtowns Animal Hospital, discuss their care with our veterinary team, and make medical decisions on your behalf during the appointment. THIS AUTHORIZATION IS FOR ONE APPOINTMENT ONLY.
Pet Name(s):
Date of Appointment:

MonthDayYear
Date
Designated Representative
THIS AUTHORIZATION IS FOR ONE APPOINTMENT ONLY.

I authorize the following individual, who is 18 years of age or older, to bring my pet to Southtowns Animal Hospital and make medical decisions regarding my pet's care during this visit. This authorization is valid for this appointment only.

My designated representative may discuss my pet's care with the veterinary team and approve recommended services, including but not limited to examinations, diagnostics, treatments, medications, vaccinations and preventive care. I understand that I am financially responsible for all services authorized by my designated representative.

I understand that unexpected medical situations may arise while my pet is at Southtowns Animal Hospital. I authorize the veterinary team to provide necessary care to stabilize my pet and prevent unnecessary pain or suffering, and I authorize my designated representative to make medical decisions regarding recommended care during an emergency situation. This authorization includes decisions regarding end-of-life care, including humane euthanasia, if recommended by the attending veterinarian.
Name of Designated Representative:
Relationship to Owner:
Phone Number for Designated Representative:
Format: (000) 000-0000.
Owner Name (Print):
Owner Signature:
Date:

MonthDayYear
Date
Should be Empty:

Pet Care Authorization Form

Designated Representative