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Medical Decisions Authorization Form

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Medical Decisions Authorization Form

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form completely.
If you have any questions, we’ll be glad to assist you!

Authorization to Make Treatment Decisions

Pet's Name *

Authorized individual(s)

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Treatment authorization begins *

Treatment authorization ends

If no end date is selected then authorization is in effect until we receive written notification from you to end the authorization

Additional Instructions

I, the undersigned owner of the pet(s) identified above, certify that I am eighteen years of age or over and authorize the listed individual(s) to make treatment decisions, up to and including euthanasia, for the pet(s) identified. I also agree to pay for all procedures/treatments performed and follow the financial policy of Mountain View Veterinary Health Center. Any payment arraignments must be made with the practice manager before services are performed. All fees are due at the time of service/discharge.

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Please Type your name *

Date *

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Email *

You will receive pet health reminders, appointment reminders and other information from us through email. You can opt out of any type of email communication through our online portal or the email itself.

Phone *

You may receive appointment reminders via text message. You can opt out of these reminders at any time.

Medical Decisions Authorization Form

Medical Decisions Authorization Form

Authorization to Make Treatment Decisions

Schedule Your Appointment

Mountain View Veterinary Health Centers – North Logan

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Mountain View Veterinary Health Centers – Providence

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