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Authorization to Treat

Pet Name*

Name of person(s) authorized to make medical decisions:*

Phone Number(s) of person(s) authorized to make medical decisions:*

I do hereby authorize the emergency contact person listed on this form to make medical and health care decisions for my pet(s) in my absence. In the event of an emergency, I understand that LRAH will attempt to contact me at the phone number(s) provided; however, I understand that if I cannot be reached within a reasonable amount of time (as determined by LRAH based on the urgency of medical care), I authorize LRAH to treat my pet however is deemed necessary for its health and well-being. Furthermore, I acknowledge that payment for any and all expenses will be due at the time of service.
Please initial your selection below.*

Please treat my pet as required, you do not have to call me.
Perform only emergency treatment, and notify me for permission for further treatment.

In the unlikely event that your pet is facing an urgent and immediate life-threatening condition, we will do everything in our power to ensure his or her continued comfort. If your wishes are a humane end to their suffering, please initial below.*

Yes, if the doctor feels that recovery is not possible
No, please keep my pet comfortable until I return