Medical Proxy FormAnimal Emergency Clinic of the Hudson Valley

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a dog sitting next to a person

If I am unable to make veterinary medical decisions for my pet, I hereby appoint the following individual(s) as my authorized veterinary medical proxy(ies):

Authorization Details:

I grant my appointed proxy(ies) the authority to make any and all medical decisions on behalf of my pet, including but not limited to:

- Consent to medical examinations, treatments, surgeries, and procedures.
- Administering medications and vaccinations.
- Making end-of-life decisions, including euthanasia.

Cost Acceptance Clause:

I understand and accept full financial responsibility for any and all costs associated with the medical treatment and care provided to my pet under the decisions made by my appointed proxy(ies).

Emergency Provision:

In the event that neither I nor my appointed proxy(ies) can be reached in an emergency situation, I authorize the attending veterinarian to provide immediate medical care as reasonably deemed necessary for the well-being of my pet. I understand and accept full financial responsibility for any and all costs associated with the foregoing emergency treatment and care provided to my pet.

Term of Authorization:

This authorization is effective as of ____________(mm/dd/yyyy) and shall remain in effect until revoked by me in writing.