Authorization for Treatment and Financial Consent

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This field is for validation purposes and should be left unchanged.

Owner Name(Required)

Authorized Representative’s Name(Required)

Phone(Required)

Pet's Name(Required)

Applicable Starting Date(Required)

Applicable Ending Date(Required)

I grant permission to (check all that apply):(Required)

Approve and consent to medical examinations, diagnostics, and treatments as recommended by the attending veterinarian.

Make medical decisions on my behalf during the visit.

Accept financial responsibility for any charges incurred during the visit, with the understanding that I remain ultimately responsible for payment.

By signing below I hereby authorize the above representative to bring my pet(s), to Beacon Veterinary Specialists for veterinary care on the date listed above. This authorization is valid for the above date(s) only.(Required)

Authorization for Treatment and Financial Consent

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