Home Absent Owner Treatment Consent Form

Absent Owner Treatment Consent Form

Owner Name

Owner Email

Owner Phone Number

Owner Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Authorized Agent Name

Authorized Agent Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone Number

Pet Name

Species

Breed

Age

Sex

Color

I,

appoint (Authorized Agent)

as my attorney-in-fact, to do all that is necessary or desirable for maintaining the health of the above described pet; specifically, to approve and authorize any and all medical treatment deemed necessary by a duly licensed veterinarian and to execute any consent, release, or waiver of liability required by veterinary authorities incident to the provision of medical, surgical or other essential care to my dog by qualified veterinary medical personnel.

This limited power of attorney, goes into effect as of (Date)

and will cease as of (Date)

My agent may authorize, without approval from me, veterinary services up to and including $.

specify amount

any amounts over and above that will require that the veterinarian contact me for discussion and approval at

Owner Signed

Date

Absent Owner Treatment Consent Form

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