Veterinary Treatment Authorization & Consent Form (Page 2 of 2) in pdf

Veterinary Treatment Authorization & Consent Form Page 2

If above named veterinarian is not available, another veterinarian in his/her

veterinary group is/is not acceptable. (_____ Initial) I understand that Make

My Day Please, LLC assumes no responsibility for the loss of any pet and is

released from all liability related to transportation, treatment and expense.

(___ Initial)

I do/do not agree to authorize said veterinarian to euthanize my pet in extreme

circumstances under his/her advisement after all reasonable attempts have

been made to reach me. (_____ Initial)

This consent for treatment has no expiration date unless otherwise noted. A

photocopy/facsimile of the signed consent shall have the same force and effect

as the Client/Pet Owner’s original signature. (_____ Initial)

If the veterinary office named above is unavailable, I authorize Make My Day

Please, LLC to take my pet to the veterinarian office or clinic of their choice

for treatment. (_____ Initial)

I have made advance arrangements with your office to pay all charges and

fees that are incurred on my behalf, immediately upon my return.

*Signed _____________________________________________________

OR PLEASE charge all expenses incurred for veterinary services to this card:

M/C

Visa

Other (Name of Card)

Name on Card:

CC# and Exp. Date:

Signature If Different Than Pet Owner:

Pet Owner Name:

Address:

City:

ZIP:

Home Phone:

Cell/Pager:

Work Phone:

Other:

This form will be retained on file and will be used to authorize veterinary

treatment in the event that your pet(s) require(s) treatment during your

absence, while in our care, and we are unable to contact you at the time.

Should you change veterinarians please notify Make My Day Please, LLC

before service dates. A copy will be sent to the primary veterinarian listed

above to be retained in the medical file(s) of your pet(s).

Veterinary Treatment Authorization & Consent Form Page 2