Hagersville Veterinary Services Pet Care Emergency Authorization Form

Complete this form to give us permission to treat your pet in an emergency situation if you cannot be reached.

Emergency Care Permission Form

The authorized agents listed on this form are permitted to make emergency veterinary medical decisions for the animal(s) described below in the event that I cannot be reached. Where applicable, I have also provided guidelines and limitations regarding care. Financial responsibility for the emergency care of the animal(s) listed below will be assumed by the authorized representative.

Owners Name *

First

Last

Contact Number *

Email *

I can be reached at this number at all times: *

Owner’s Contact Information in case of emergency:

Pet Information – Please list all pets to which this form applies

Please provide the name, species, breed (if known), and age of each pet to which this form applies. Include all pets currently under your care.

1. *

Authorized Agents Information

(Authorized agents MUST be 18 years of age or older)

Full Name *

First

Last

Relationship to Pet Owner

Authorized Agent’s Phone Number *

Additional Contact Information for Authorized Agent

Euthanasia Instructions (Please select one option) *

I DO authorize euthanasia without my direct consent.
I DO NOT authorize euthanasia without my direct consent.

I authorize emergency veterinary care costs up to: (Please select one option) *

Up to $1000
$1000-$5000
Other

Signature *

Clear Signature

If Phone can

Today's Date *

Additional Information About Your Pet’s Health, Care, or Special Needs

Hagersville Veterinary Services Pet Care Emergency Authorization Form

Emergency Care Permission Form

Pet Information – Please list all pets to which this form applies

Authorized Agents Information

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Have a Question?

Address

Contact

Hours

Our After-Hours Emergency Process in Hagersville, ON

If you are in need of emergency care, please contact one of the following clinics: