Authorization to Treat - Animal Emergency Trauma Center

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Authorization to Treat Pet(s)

Click here to print Authorization to Treat form and fax to 360-697-7934, or fill out the form below to submit online.

Please submit one form per pet.

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

Private Cremation

<50 lbs - $278.75
50-100 lbs - $375
>100 lbs - $471.25
>151 lbs - $555

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: *

State: *

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. *

Animal Emergency and Trauma Center
320 Lindvig Way
 Poulsbo, WA 98370

360-697-7771
360-697-7934 fax

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