Emergency
Vet
Authorization

Pet Care Emergency Authorization Form

I, , owner of the below-described dog(s), authorize Ann Gardner to make emergency veterinary medical decisions for the dog(s) described below in the event that I cannot be reached. Where applicable, I have also listed guidelines and limitations of care below. I accept full financial responsibility for the emergency care of the dog(s).

Owner's name:
Owner's address:
Owner's city:
state:
zip:
Owner's phone:
Any additional contact information in case of emergency:

Alternate contact (optional):

Dates of travel or expiration date of this form (12/31/current year recommended for multiple stays):

Dog(s)'s name(s):
Dog(s)'s breed:
Age, weight, sex:
Description (color, markings):

Relevant medical history:

Microchip number (optional):

Vaccinations and dates (rabies info at minimum):

Medications. Include dose and frequency:

Brand and flavor of food:
How often and how much:

Authorized Agent:
Ann Gardner
(860) 515-8780
Berlin CT 06037

If possible, the authorized agent will bring my dog(s) to the following veterinarian:
Vet Name:
Vet Address:
Vet phone:

I give permission for the authorized agent to bring my dog(s) to the veterinarian of their choice if my vet is not available.

I authorize and agree to pay emergency veterinary care costs up to:

I do not authorize the following procedures/treatments. Provide a description of what is to be done in place of these procedures/treatments:

Other Instructions:

I have filled out the above information truthfully on this date

Signed:

(may need to click "Submit" twice)