Fillable Printable Caregiver Consent Form for Medical Treatment
Fillable Printable Caregiver Consent Form for Medical Treatment
Caregiver Consent Form for Medical Treatment
Caregiver Consent Form for Medical Treatment
I, ___________________________________________, hereby voluntarily consent to the rendering of
such care, including diagnostic procedures, surgical and medical treatments by medical doctors, hospitals
or their authorized designees, as may in their professional judgement be necessary to provide for the
medical, surgical or emergency care of my pet, ____________________________________________.
(Pet’s Name)
I further give my consent to _____________________________________________________________,
(“Caregiver”) – Full Name
whom will be caring for my dependent for the period ________________ through _________________,
to arrange for routine or emergency medical and/or dental care and treatment necessary to preserve the
health of my pet.
In making medical decisions on my behalf for the benefit of my pet, I direct that the caregiver attempt to
contact me. However, if medical care becomes essential, I give permission to the caregiver to make such
decisions regarding such treatment as deemed appropriate by the medical doctor, hospital or their
authorized designee. In furtherance of any treatment decisions to be made by the caregiver on my behalf
for the benefit of my pet, I authorize the caregiver to request, obtain, review and inspect any and all
information bearing upon my pet’s health and relevant to any such decisions to be made respecting such
treatment.
I acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment
on the condition of my pet and that I am responsible for all reasonable charges in connection with the care
and treatment rendered to my pet during this period.
I will allow treatment costs up to $500
I will allow treatment costs up to $1000
I will allow any and all treatment costs
____________________________________ ____________________________________
Name of Pet Owner Home Address
____________________________________ ____________________________________
Primary Phone Secondary Phone
____________________________________ ____________________________________
Away Address Away Phone
______________________________________________________ ______________________________________________________
Caregiver Name Caregiver Phone
____________________________________ ____________________________________
Pet Name Species/Breed
____________________________________ ____________________________________
Current MedicationsPet Insurance Provider/Policy Number
____________________________________ ____________________________________
Signature of Pet Owner Date
