Temporary Guardianship Form - Chester Valley Veterinary Hospital

Owner *

Chart number

Pet's name *

Phone *

Email *

Alternate phone

I am going to be out of town for the following dates: *

I am the legal owner of this animal.

Date leaving *

Date returning *

I am leaving my pet in the temporary guardianship of: *

I hereby grant the temporary guardian my full authorization to make decision as to general first aid treatment for any minor injuries or illnesses experienced by my pet. If the injury or illness is life threatening or in need of emergency treatment, I authorize the temporary guardian to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by Chester Valley Veterinary Hospital. *

Digital Signature

Euthanasia *

I give consent for the temporary guardian to be able to make the decision to euthanize my pet if deemed necessary by Chester Valley Veterinary Hospital in the event of an emergency or accident.
I DO NOT give the temporary guardian permission to make the decision the euthanize my pet under any circumstance.

Comments or extra instructions:

I understand that I am fully responsible for all charges accrued during treatment that will be paid on the day of services rendered by myself over the phone or by the temporary guardian. *

I agree and understand

Has your pet been seen previously by a veterinarian? *

Yes
No

Please have your previous veterinarian send all previous medical history for your pet via email (healthypetalaska1@gmail.com) or fax (907-337-4311) PRIOR to your scheduled appointment. Failure to have previous records prior to a scheduled appointment can result in both a delay in care and a medical records retrieval fee.

Digital signature

Date *