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Consent to Treat Form

The following form is intended for use when a pet owner will be away and may be unavailable to make medical decisions for their pet. By completing this form, you authorize the individual(s) listed below to make medical decisions and consent to recommended veterinary care on your behalf during your absence.

Pet Owner Information

Dates Away

Authorized Individual

Payment Information

Some owners choose to leave credit card information on file to help cover the cost of veterinary care in the event of a medical emergency.

Any credit card information provided will be securely deleted after your expected return date. Please note that if we recommend transferring your pet to a local emergency veterinary hospital for advanced care, we will not be able to share your payment information with that facility or with the authorized individual listed above. You will be responsible for making payment arrangements directly with the emergency hospital. Please call our office at 518-446-9171 to give payment information securely over the phone.

Authorization & Signature

By signing below, I authorize the individual(s) listed above to make medical decisions and consent to veterinary treatment for my pet(s) during the dates specified. I understand that I may be contacted at the phone number provided, when possible, but that this authorization allows the designated individual(s) to act on my behalf if I cannot be reached.

Clear Signature