Owner’s name:(Required)

Owner’s contact information in case of emergency:(Required)

Predicted Dates of Travel(Required)

*This form will be valid for the duration of these dates only*

I give permission for the pet sitter to care for my pet in my absence. He/she has my permission to transport them to and from your clinic or request “on site” treatment from your office as is deemed necessary, and make medical decisions. I further authorize you to give out any information about my pet to those listed below as Authorized People.(Required)

I give permission

Authorized Person #1(Required)

Relationship to pet owner:(Required)

Contact information for authorized agent:(Required)

Add additional authorized people(s) to my account indefinitely until I remove

Yes

Authorized Person #2(Required)

Relationship to pet owner:(Required)

Contact information for authorized agent:(Required)

Animal’s name:(Required)

Type of animal:(Required)

Relevant medical history or chronic medications:(Required)

I authorize emergency veterinary care costs up to:(Required)

$250

$450

$600

$1000

Cardiopulmonary Resuscitation (CPR) Directive

If your pet suffers respiratory arrest (stops breathing) or cardiac arrest (the heart stops), we need to know your wishes concerning treatment. If either respiratory arrest or cardiac arrest occurs, your pet will die unless immediate resuscitation attempts are started. I understand ABC Veterinary Hospital Pacific Beach requires a CPR status. I acknowledge that the attending veterinarian or staff members of ABC PB will make every effort to contact me regarding treatment in the case of this unforeseen event. The initial cost of CPR, Oxygen and Emergency Injections start at approximately $800.

CPR means “Cardio Pulmonary Resuscitation” and is the treatment (resuscitation) of a pet who has stopped breathing or whose heart has stopped beating. Resuscitation of a pet who has stopped breathing but still has a heartbeat is more likely to succeed than resuscitation of a pet with no heartbeat.

DNR means “Do Not Resuscitate.” This means that if a pet stops breathing or his/her heart stops, no effort will be made to attempt to revive the pet, and the pet will die.

I am the owner / agent of this pet and(Required)

I AUTHORIZE CPR and Emergency Efforts for my pet

I DO NOT AUTHORIZE CPR and Emergency Efforts (DNR) for my pet

I accept financial responsibility for the emergency care of the animal(s), and have left my payment information with ABC Veterinary Hospital Pacific Beach. By signing below, I release ABC Veterinary Hospital Pacific Beach and its officers of liability and financial charges accrued on my credit card.(Required)

I understand

I have confirmed the Credit Card on file can be used to process all fees and charges incurred on my pet’s behalf upon the day of service.(Required)

I confirm

Duration of Validity for the above (return date):(Required)

Signature(Required)

Date(Required)

Client FormPet Sitter Emergency Medical Care Release Form & Treatment Authorization

Pet Sitter Emergency Medical Care Release Form & Treatment Authorization

Book an appointment!

questions?Get in Touch

Our Location

Our Contact Information

Our Hours