Authorization to Treat - Animal Emergency Trauma Center

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Today's Date: *

Pet Owner's Name:

Email: *

Pet's Name: *

Appointed Guardian's Name:

I hereby authorize Animal Emergency and Trauma Center to treat my Pet in my absence.

I authorize all treatments necessary for (Pets Name Above) health and wellbeing and allow the doctor on duty and/or (Appointed Guardian above) to make any medical decisions necessary to treat the problem, alleviate pain and suffering, and perform euthanasia if it becomes medically necessary and I cannot be reached in a reasonable time frame.

I promise to pay upon my return for needed health care.

The amount not to exceed:

If euthanasia must be performed, I wish the body to be: (choose from group cremation or private cremation)

Group Cremation

<50 lbs - $120
50-100 lbs - $150
>100 lbs - $195

Please note the cremation charge is in addition to the limit you set for treatment of your pet.

List any phone number(s) that you may be reached at during your absence.

List an alternate contact person with permission to authorize treatment and made decisions on your behalf:

List any medications, dosages, and reason for use your pet takes or has taken within the last month:

Owner's Name: *

Address: *

City: *

Zip: *

Owner's Phone: *

Regular Family Veterinarian:

Phone Number of Family Veterinarian:

By checking this box I am signing and agreeing to the terms set forth here. *

EMERGENCIES

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