Pet Care Emergency Authorization Form

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Please use this form if your pet will be in the care of another person or organization (such as a boarding facility) to allow them to obtain emergency veterinary care at North Heritage Animal Hospital during your absence. Once completed, you will be emailed a copy of the form that you should provide to your pet's caretaker. If they should need to seek emergency care at another hospital, they should take this form with them.

Email *

Dates of Travel or Expiration Date of This Form: *

Your First and Last Name: *

Pet Information

Please list detailed information for each of your pets - include their name, age, breed, sex and spayed/neutered status, and any medications that they are receiving.

Emergency Contact Information For Yourself

Please consider all possible ways that we may be able to reach you. This may include email, text, resort phone number, travel companion's cell phone, etc.

Authorized Agents

In the event that I cannot be reached, I authorize the agent(s) listed below to make emergency veterinary medical decisions for the pet(s) listed. Where applicable, I have also listed guidelines and limitations of care (located in next section of this form) and accept financial responsibility in the event of emergency care.

Please list the Authorized Agent(s) name, relationship to yourself, and contact information:

Payment Information

Please note that the credit card option is only available to be used at North Heritage Animal Hospital and any emergency care at another hospital would require upfront payment by yourself or the caretaker.

I have provided a credit card number to North Heritage Animal Hospital which can be used in the event of an emergency/hospital visit. This information is stored securely and electronically.

The authorized agent will be responsible for any cost incurred and will pay at the time of service.

I am available to provide a credit card number over the phone, if needed

Required

I authorize emergency veterinary care costs up to (please provide a dollar value): *

Guidelines/Limitations to Care

If you have specific instructions on what type of care or procedures you would want for your pet, please list them here:

In the event that humane euthanasia is a potential or recommended treatment option: *

I do NOT authorize euthanasia without my direct consent

This decision may be made by an authorized agent if I cannot be reached in a timely manner

Required

If my pet should pass away, either through humane euthanasia or otherwise, I request the following handling of remains: *

Home burial

Communal Cremation (ashes are NOT returned to you)

Private Cremation (ashes are returned to you)

Required

By typing your full name below, you agree that your electronic signature is the legal equivalent of your manual/handwritten signature on this document. *

A copy of your responses will be emailed to the address you provided.

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