PLEASE CALL AHEAD BEFORE COMING, IN CASE WE ARE AT FULL CAPACITY, THIS MEANS THAT WE FILLED WITH EMERGENCY PATIENTS AND CAN NO LONGER TAKE IN ADDITIONAL PATIENTS. WE WANT TO ENSURE THAT EVERY PATIENT GETS THE PROPER CARE SO WE WILL DIRECT YOU TO ANOTHER EMERGENCY HOSPITAL.

Medical Proxy FormAnimal Emergency Clinic of the Hudson Valley

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I, the undersigned owner or agent of the pet residing at [Owner's Address], certify that I am the legal owner of the following pet: *

I have read and agree

Owner's Full Name *

First

Last

Owner's Email *

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age *

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):

1. Proxy's Name *

Relationship to Owner *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

2. Proxy's Name

Relationship to Owner

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

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.

Date *

Signature *

Clear Signature

Name *

First

Last

Medical Proxy FormAnimal Emergency Clinic of the Hudson Valley

Authorization Details:

Cost Acceptance Clause:

Emergency Provision:

Term of Authorization:

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