Veterinary Treatment Authorization & Consent Form

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Veterinary Treatment Authorization & Consent Form
Primary Veterinary Information
Name of Clinic:
Address:
City:
Phone:
Zip Code:
Fax:
To whom it may concern: During my absence a representative of Make My
Day Please, LLC will be caring for my pet(s). I give Make My Day Please,
LLC my permission to transport my pet(s) to you, my veterinarian (or to an
emergency clinic). In the event I cannot be reached, I authorize Make My Day
Please, LLC to act as an agent on my behalf regarding the medical care of my
pet(s). I authorize veterinary treatment and accept full responsibility for
charges incurred in the treatment of my pet(s), not to exceed the following
amounts for each pet:
Pet Name
Description
Maximum Amount
Check here if additional pets are listed on the reverse side.
* This form MUST be signed to authorize treatment.
_____________________________________________________________
Client Printed Name ................................................................Signature/Date

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