To Whom it May Concern:
I, owner of the pet listed below, authorize the authorized agent listed below to make emergency veterinary medical decisions, including euthanasia (unless noted below) for the animal described below in the event that I cannot be reached. Where applicable, I have also listed guidelines and limitations of care. I accept financial responsibility for the emergency care of the animal(s).
Phone * Email * Emergency Phone * Emergency Email * Animal's Name * Type of Animal * Age, weight, and sex of animal * Description of animal (color, markings) * Relevant Medical History * Microchip Number (if available) Vaccinations (vaccination, date) * Medications (name, dose, frequency, route of administration, other notes) Relationship to owner * Phone of Authorized Agent * Email of Authorized Agent * Other Instructions, if applicable How much do you authorize for emergency veterinary care? * Do you authorize euthanasia without direct consent? * In the event of my animal's death, I wish for the following to be done with his/her remains: * I do not authorize the following procedures/treatments
Please provide a description of what is to be done in place of this procedure/treatment