Testing Medical Power of Attorney I, the undersigned owner of my pet, named , certify that I am over eighteen years of age and hereby appoint:*Name:*Address: Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone:Fax:... as my agent to make any and all healthcare decisions for my pet, except to the extent I state otherwise in this document. My agent shall follow my wishes as set forth through this document or other means. If my agent cannot determine the choice I would want for my pet, then my agent's decision shall be based upon what he or she believes to be in my pet's best interest. This medical power of attorney also takes effect if I become unable to make healthcare decisions for my pet and this fact is certified in writing. I authorize up to (check one and indicate amount)*$200$300The following sets forth limitations on the decision-making authority of my agent (initial one):* The agent's decisions must be made in accordance with the living will directive for my pet, executed on this date I agree to pay for all authorized services as long as the fees for my pet's medical care do not exceed $ (amount specified above) No limitations shall be imposed on my agent I understand that this power of attorney revokes any prior medical power of appointment and shall exist indefinitely from the date I execute this document unless I establish a shorter time or revoke the power of attorney. If I am unable to make healthcare decisions for my pet and this power of attorney expires, the authority I have granted to my agent shall continue to exist until the time I am able again to make healthcare decisions for my pet. This power of attorney ends on the following date: Date Format: MM slash DD slash YYYY If the person designated as my agent in unable or unwilling to make healthcare decisions for my pet, i designate the following alternative person to serve as my agent to make healthcare decisions for my pet as authorized by this document. Name:Address: Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone:Fax:I hereby sign my name to this medical power of attorney.Signature*Date* Date Format: MM slash DD slash YYYY Phone This iframe contains the logic required to handle Ajax powered Gravity Forms. CLIENT INFORMATION PLEASE PRINT Date Date Format: MM slash DD slash YYYY Name First Last Spouse's Firest NameAddress Street Address City ZIP / Postal Code Home PhoneEmail Cell Phone # or Pager #Employer NameAddress Street Address City ZIP / Postal Code Occupation or TitleBusiness PhoneSpouse's Emplyoer NameAddress Street Address City ZIP / Postal Code REFERRED BYProfessional fees are to be paid at the time they are rendered. Signature of Owner*Signature of person presenting this pet if other than owner*Relationship to ownerAddress of non-owner Street Address City ZIP / Postal Code PhoneANIMAL INFORMATIONPet's Name*BreedSexNeuteredCircle OneDogCatBirdOtherBirthdayColorWeightPrevious Medical Problems:Allergies to Medications:Other:Pet's NameBreedSexNeuteredCircle OneDogCatBirdOtherBirthdayColorWeightPrevious Medical Problems:Allergies to Medications:Other:Pet's NameBreedSexNeuteredCircle OneDogCatBirdOtherBirthdayColorWeightPrevious Medical Problems:Allergies to Medications:Other: This iframe contains the logic required to handle Ajax powered Gravity Forms. Avian History Form This information will become a permanent part of your bird's medical record. Please take time to complete it as carefully as possible. THANK YOU! Bird's Name:*Owner's Name:*Date Date Format: MM slash DD slash YYYY How long have you had this bird?Where did you acquire it?What do you feed your bird? (Please be specific)Seeds % of dietVegetables % of dietFruit % of dietPellets % of dietWhat time does your bird wake up in the morning?What time does your bird go to bed?Where is the cage located? Kitchen Family Room Bedroom Other What kind of bedding does your pet have? Newspaper Shavings Paper Towels Corncob Pellets Does your bird appear to have any symptoms? Explain:Is your bird... Fluffed Lethargic Not vocalizing Vomiting At the bottom of cage Difficulty breathing When did these symptoms first appear?Has your bird had any previous illnesses? Please specify:Have you noticed any discharge or change in color/consistency of droppings?Has your bird's appetite/behavior changed in any way? Please specify:Does your bird do any plucking or preening in your presence?YesNoWhen did it start?Do you give your bird any supplements?YesNoWhat kind?Has your bird received any medications recently?YesNoIf yes, please list them:Has your bird had any blood, culture, or fecal tests recently?YesNoAny recent changes to your home or your bird's environment? Explain:Has quality time or daily routine with your pet changed recently?YesNoHas your bird traveled anywhere outside the home recently?YesNoDoes your bird have any cage mates?YesNoIf yes, are they showing any signs of illness?YesNoDoes your pet spend any time outside (backyard)?YesNoHas any new birds been added to your aviary or household?YesNoHas your bird boarded/ or been groomed recently?YesNoIf yes, where?Do you have any other questions or concerns?Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms. BOARDING AGREEMENT Today's Date Date Format: MM slash DD slash YYYY Date of pick-up Date Format: MM slash DD slash YYYY Time : HH MM AM PM Owner*Pet's Name*Additional Services: (see below) $BatheYesNoGroomYesNoMedicationsYesNoCapstarInOutPet(s) Boarding: (Estimated Cost) Nights @ $Nights @ $Nights @ $Person(s) to contact in case of emergencyTelephone number(s)Special Instructions - include detailed medication directions, feeding instructions, and anything you wish the doctor to check for.VACCINATION POLICY To insure the protection of all pets under our care, the following must be up-to-date: DOGS: RabiesDHPPBordetellaPhysical ExamCATS: RabiesFVRCPBordetellaPhysical ExamAVIAN: PsittacosisGram (optional)Fecal (optional)Physical ExamIf not up-to-date, or unable to provide proof of vaccination, I give permission to update my pet(s) vaccination in accordance with the above policy. In addition, if any fleas/ticks are observed on you pet(s) while boarding, he/she (they) will receive treatment (Advantage or Frontline) at the owner's expense. Estimated Total: $MEDICAL ILLNESS POLICY One of the advantages of boarding your pet(s) at a veterinary hospital is that veterinary attention is readily available should the need arise. If your pet(s) becomes ill, we will call the emergency number(s) listed above regarding your pet's symptoms, treatment options and estimate of additional cost. If no one can be reached however, please indicate your wishes below should your pet(s) require treatment to relieve immediate discomfort or to resolve an important medical condition, (INITIAL) Please perform whatever services the doctor deems necessary for the best care of my pet until someone can be reached. This includes only non-elective treatment and necessary diagnostics.I authorize up to (check one and indicate amount)*$200$300(INITIAL) Do not administer any medical treatment until specific authorization is given.I have read and understand this agreement. I fully intend to pick up my pet(s) on the above-specified date. If circumstances change, I will notify the veterinarian of a new pick-up date. I hereby authorized to pick up my pet/pets in case I am not available(payment/picture ID required) Signature*Date* Date Format: MM slash DD slash YYYY Special Instructions: Food: Wet Dry Both Hospital (EN dry)(Name of food)Did you already feed for the day?YesNoDo you feed? 1x a day 2x a day all dayAmount given/ any other special instructions?Belongings:Meds: : NameHow many?What time?Do you give medication with food or treats?YesNoWere medications already given?YesNoAny other special instructions?Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.
