Authorization For Emergency Treatment

AUTHORIZATION FOR EMERGENCY TREATMENT

I will be out of town from Out of Town Start Date to Out of Town End Date . I give authorization for Authorized Person Name to seek emergency medical treatment for my animal(s) while I am away. I authorize up to $ Authorized Dollar Amount in Treatment I would prefer Dr. Preferred Doctor's Name to treat my animal(s) if he/she is available and on duty on the day of the emergency. My emergency contact number is: Emergency Contact Phone Number My email address is: Your Email Please sign here:
Please print your name Printed Name Today's date Today's Date By submitting this form, you agree to be contacted via the info given through email, phone call, or text message