Medical Decisions Authorization

Authorization to Make Treatment Decisions
Your Name*

First NameLast Name
Your Phone Number*

Area CodePhone Number
Your Email*
example@example.com
Pet's Name(s)*
Please list each pet this applies to. Separate with a comma.
Authorized Individual(s)*

First NameLast Name
Authorized Individual(s)

First NameLast Name
Authorized Individual(s)

First NameLast Name
Authorized Individual(s)

First NameLast Name
Treatment Authorization Begins*

MonthDayYear
Treatment Authorization Ends

MonthDayYear
If no end date is selected then authorization will remain in effect until we receive written notification from you to end the authorization.
Additional Instructions
I, the undersigned owner of the pet(s) identified above, certify that I am eighteen years of age or over and authorize the listed individual(s) to make treatment decisions, up to and including euthanasia, for the pet(s) identified. I also agree to pay for all procedures/treatments performed and follow the financial policy of Mountain View Veterinary Health Center. Any payment arraignments must be made with the practice manager before services are performed. All fees are due at the time of service/discharge.
Please Sign*

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Authorization to Make Treatment Decisions