Pet Care Emergency Authorization Form

Which practice would you like to register with?

Location

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The authorized agents listed on this form are authorized to make emergency veterinary medical decisions for the animal(s) described below in the event that I cannot be reached. Where applicable, I have also listed guidelines and limitations of care. Financial responsibility for the emergency care of the animal(s) listed below will be handled by the authorized representative.

OWNER INFORMATION

Full Name *

I authorize the agent(s) listed on this form to make emergency veterinary medical decisions for the animal described below in the event that I cannot be reached. Where applicable, I have also listed guidelines and limitations of care.

Phone Number *

I can be reached at this number at all times

Yes No

Contact information *
Owner’s contact information in case of emergency (provide all forms of contact).

Other contacts *
Other contacts (travel companions, etc. – name and contact information).

Dates of travel or expiration date of this form. *

PET INFORMATION

Pets *
List all pets that this form applies to.

AUTHORIZED AGENTS INFORMATION

Authorized agents MUST be 18 years of age or older.

Authorized agent's name *

Authorized agent's phone number *

Relationship to pet owner *

Contact information for authorized agent *

Authorized agent #2

Authorized agent #2 phone number

Relationship to pet owner

Contact information for authorized agent #2

Euthanasia Instructions *
Note: If your agent is available, consent for treatments will be obtained from them. If they are not available, treatment decisions will be made by the veterinarian on the case.

No euthanasia without my direct consent - do all recommended treatments to stabilize my pet until I'm available.
Humane euthanasia can be performed in emergency scenarios if costs required to treat exceed my authorized treatment limit as indicated below.

I authorize emergency veterinary care costs up to *

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Pet Care Emergency Authorization Form

Which practice would you like to register with?

OWNER INFORMATION

PET INFORMATION

AUTHORIZED AGENTS INFORMATION

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