Home and Heart ER Approval Form
In the event of an unforeseen emergency, this form lets us know how you want your pet's care managed.
Date
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Month
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Day
Year
Date
Client Name First and Last
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Veterinarian Notification/ Agreement to Treat
I, ____________________________, give Home and Heart Pet Care, LLC authorization to care for my animal(s) during my absence, including veterinary care. They are authorized to transport my animal(s) to your hospital for treatment. I authorize you, the veterinarian, to treat my animal(s) and I am fully responsible for payment upon my return. Home and Heart Pet Care, LLC is not responsible for any payment.
Pet’s Name 1
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Pet’s Name 2
ER Max Amount (USD)
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In the event of a life threatening emergency, do you have a preference regarding resuscitation (CPR)? If your pet's heart or breathing were to stop, would you want us to initiate CPR if appropriate, or would you prefer a Do Not Resuscitate (DNR) directive?
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Initiate CPR if appropriate
Do Not Resuscitate (DNR)
Client Signature (General Treatment Authorization)
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In the case that euthanasia is warranted by the DVM, I authorize Home and Heart Pet Care, LLC to act on my behalf.
Client Signature (Euthanasia Authorization)
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After care request
Submit
Submit
Should be Empty: