24-HR ER: 808-735-7735
Our Services
Cardiology
Diagnostic Imaging
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Interventional Radiology
Neurology
Oncology
Physical Therapy & Rehabilitation
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For Your Pet
Emergencies + Appointments
When Your Pet is a Patient
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Animal Blood Bank of Hawaii
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At a Glance
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Animal Blood Bank of Hawaii
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Ethos Discovery
Contact Us
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PAWEDcasts
Careers + Development
VERC is Hiring
Positions Across Ethos
Benefits and Perks
Veterinary Training Programs
Our Services
Cardiology
Diagnostic Imaging
Emergency/Critical Care
Internal Medicine
Interventional Radiology
Neurology
Oncology
Physical Therapy & Rehabilitation
Surgery
For Your Pet
Emergencies + Appointments
When Your Pet is a Patient
Client Portal
Pet Insurance
Payment Options
Grief Resources
Animal Blood Bank of Hawaii
Clinical Studies
FAQs
For Veterinary Teams
Our Referral Process
Submit Referrals
At a Glance
Ethos Materials for Clinics
Continuing Education
VetBloom CE
Clinical Studies
Animal Blood Bank of Hawaii
About Us
Our Hospital
Our Team
Why Ethos
Ethos Discovery
Contact Us
Blogs
Our Blogs
PAWEDcasts
Careers + Development
VERC is Hiring
Positions Across Ethos
Benefits and Perks
Veterinary Training Programs
24-HR ER: 808-735-7735
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
Hawaii
Armed Forces Pacific
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
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.
Name
This field is for validation purposes and should be left unchanged.
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