Proxy Form

Save time during your appointment! Complete your required proxy form online from any device at any time before your visit.

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Proxy Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Owner's Name *

First

Last

Owner's Phone *

Owner's Email *

Owner's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pet's Name *

Species *

Breed *

Age/Date of Birth *

I certify that I am the legal owner of the above-named pet. If I am unable to make veterinary medical decisions for my pet, I hereby appoint the following individual(s) as my authorized veterinary medical proxy(ies) (listed below). *

I certify

Proxy's Name *

First

Last

Relationship to Owner *

Proxy's Phone *

Proxy's Email *

Proxy's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Would you like to add another proxy? *

Authorization Details: I grant my appointed proxy(ies) the authority to make any and all medical decisions on behalf of my pet, including but not limited to: Consent to medical examinations, treatments, surgeries, and procedures; Administering medications and vaccinations; Making end-of-life decisions, including euthanasia. *

I authorize

Cost Acceptance Clause: I understand and accept full financial responsibility for any and all costs associated with the medical treatment and care provided to my pet under the decisions made by my appointed proxy(ies). *

I authorize

Emergency Provision: In the event that neither I nor my appointed proxy(ies) can be reached in an emergency situation, I authorize the attending veterinarian to provide immediate medical care as reasonably deemed necessary for the well-being of my pet. I understand and accept full financial responsibility for any and all costs associated with the foregoing emergency treatment and care provided to my pet. *

I authorize

Term of Authorization: This authorization is effective as of the below date and shall remain in effect until revoked by me in writing. *

Signature *

Clear Signature

Date *

Proxy Form

Proxy Form

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