Owner's Name: Contact numbers: Pet's Name Description Description Age Age Vaccine status Vaccine status Medical conditions Medical conditions Current medications Current medications CPR/DNR CPR/DNR Pet's Name: Pet's Name: Description Description Age Age Vaccine Status Vaccine Status Medical conditions Current conditions CPR/DNR CPR/DNR If any of my pets listed above needs medical attention, I authorize (Insert Name Below ) to act as their guardian, transport them to my regular veterinarian, and in the event of an emergency and/or if my regular veterinarian is not available, to transport them to Veterinary Emergency and Critical Care. The veterinarian is to first call me for authorization, but if I am unavailable and this is an emergency, the veterinarian is authorized to begin treatment of my pet(s). If I cannot be reached, I authorize the above named guardian to make necessary medical decisions for my pet(s). If I cannot be reached, I authorize the above named guardian to approve treatment of my pet(s) up to $_____________ I have indicated my wishes for either CPR or DNR (do not resuscitate) as listed for each pet above. Please treat my pet accordingly until I can be reached. Upon my return I will assume full responsibility for payment/reimbursement of veterinary services rendered up to the above stated amount, or more, if I have been contacted and have authorized further servicesOwner's Signature Date:
