Medical Proxy

Authorization for Medical Care During Owner's Absence
- I hereby give permission for the person listed below to bring my pets to Veterinary Emergency + Referral Center of Hawaii for treatment and/or surgery if it becomes necessary during my absence.
- Pet Owner First Name*
- Pet Owner Last Name*
- Caregiver's First Name*
- Caregiver's Last Name*
- Between the following Dates: From*
- Until*
- This Proxy applies to the following Pets*
  Name Species (Dog/Cat)
- In the event of a terminal illness, or at the discretion and concurrence of both the doctor and the responsible party named above, I also give permission for euthanasia*
  - No
  - Yes
Authorizations for Charges
- I agree to be responsible for all charges and authorize the following:
  - As needed for my pet's wellness and wellbeing
  - As needed, up to a specified limit
- What is the limit to the approved dollar amount?
  
  We will not exceed the dollar amount provided above.
- Special Instructions or Requests
Contact Information
A copy of this form will be emailed to you. Please print this form and ask your pet's caregiver to bring it with them, along with their ID in the event of an emergency.
- Owner's Email Address*
  
  We will use this to send you a copy of this form
- Owner's Preferred Phone Number*
- Owner's Back up Phone Number
- Owner's Address
- Address 2
- Town/City
- State
- Zip Code
- Caregiver's Preferred Number
- Consent*
  I have read and agree to the policies below
  I consent to an examination of my pet by the providers at this Veterinary Emergency + Referral Center of Hawaii. I understand that diagnostics and treatment along with the associated costs will be discussed prior to delivery and I have the right to decline. If my pet is hospitalized, I understand the provider will present an estimated treatment plan with the associated costs, however, treatment may vary throughout the duration of my pet’s stay. I will be informed of any costs that exceed the initial treatment plan so I am able to make informed decisions about my pet’s care.
  
  Payment is due at the time of service and any remaining balance must be paid when services are complete. All day services and hospitalizations require a deposit in full of the estimated cost.
  
  I understand that a photograph of my pet for identification purposes is captured and stored in the medical record. This is used identification and is not shared. This photo is compulsory as it ensures proper care for your pet while in our care.
  
  I am the legal owner or representative of the legal owner of the animal being presented and I am 18 years or older.
Email
This field is for validation purposes and should be left unchanged.

Name	Species (Dog/Cat)

Authorization for Medical Care During Owner's Absence

Authorizations for Charges

Contact Information