Authorized Representative Consent Form – Main Street Veterinary Services

Owner 1

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary phone number*

Please provide the best phone number to contact you

Primary phone type*

mobile
landline

Email - Please use the best email to contact you*

Enter Email Confirm Email

Owner 2 - Co-Owner

Is there an Owner 2 - Co-Owner listed on your file?*

Yes
No

Name*

First Last

Primary phone number*

Please provide the best phone number to contact you

Primary phone type*

mobile
landline

Email - if different than Owner 1

Enter Email Confirm Email

Authorized Representative

An authorized representative for a pet for veterinary care is an individual, aged 18 or older, who you have granted explicit permission to act on your behalf in matters relating to medical care of the pet(s) Listed below.

Name of Authorized Representative*

First Last

Address of Authorized Representative*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary phone number*

Please provide the best phone number for your Authorized Representative

Primary phone type*

mobile
landline

Authorized Representative Medical Permissions*

If you are unavailable, the individual named above is authorized to make the following Medical Decisions on your behalf when recommended by the attending veterinarian:

Select All
Routine treatment including but not limited to vaccinations, check-ups, minor illness
Treatments including but not limited to antibiotics, nutraceuticals, supplements etc.
Diagnostic testing including but not limited to bloodwork, urinalysis, cytology etc.
Radiographs
Surgery
Referral for Emergency Care or Treatment
Euthanasia

Authorized Representative Financial Permissions*

If you are unable, the individual named above is authorized to make Financial decisions on your behalf regarding the pet(s) listed below up to the dollar value of (i.e. $1000, $5000, amount necessary to cover the cost of the recommended medical permissions):

How long would you like this person to be your named Authorized Representative?*

If other, please specify the time frame you allow the named person to act on your behalf if necessary.

One week from date of notification
One month from date of notification
Indefinitely

Pet Information

The individual named above is the authorized representative is for the following pets:*

Please list the name of each pet as we have it in our records and their species (cat or dog)

Consent

Consent - Owner 1*

As the owner of the pet(s) listed above, I grant permission to the named Authorized Representative to act on my behalf in matters related to the veterinary care of my pet(s) as outlined in this form. This authorization permits the Authorized Representative to transport my pet(s) to and from the veterinary clinic, communicate with the veterinary team, and make decisions regarding necessary medical treatments, including emergency care, as recommended by the attending veterinarian. I understand that I remain financially responsible for all veterinary services provided and that this authorization will remain in effect until revoked in writing.

Consent - Owner 2 - Co-Owner*

As the co-owner of the pet(s) listed above, I grant permission to the named Authorized Representative to act on my behalf in matters related to the veterinary care of my pet(s) as outlined in this form. This authorization permits the Authorized Representative to transport my pet(s) to and from the veterinary clinic, communicate with the veterinary team, and make decisions regarding necessary medical treatments, including emergency care, as recommended by the attending veterinarian. I understand that I remain financially responsible for all veterinary services provided and that this authorization will remain in effect until revoked in writing.

When you have successfully completed this from, the browser will flash up a new window with a confirmation that you have successfully submitted this form and that an email of your answers to this questionnaire has been sent to you. If you do not receive this email, you have not successfully completed this from.*

Acknowledged