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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 $300 The 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: 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone:Fax: I hereby sign my name to this medical power of attorney.Signature*Date* MM slash DD slash YYYY Phone CLIENT INFORMATION PLEASE PRINT Date MM slash DD slash YYYY Name First Last Spouse's First Name Address Street Address City ZIP / Postal Code Home PhoneEmail Cell Phone # or Pager # Employer Name Address Street Address City ZIP / Postal Code Occupation or Title Business PhoneSpouse's Employer Name Address Street Address City ZIP / Postal Code REFERRED BY Professional fees are to be paid at the time they are rendered. I am over the age of 18* Yes No Signature of Owner* Signature of person presenting this pet if other than owner* Relationship to owner Address of non-owner Street Address City ZIP / Postal Code PhoneANIMAL INFORMATIONPet's Name* Breed Sex Neutered Circle One Dog Cat Bird Other Birthday Color Weight Previous Medical Problems: Allergies to Medications: Other: Pet's Name Breed Sex Neutered Circle One Dog Cat Bird Other Birthday Color Weight Previous Medical Problems: Allergies to Medications: Other: Pet's Name Breed Sex Neutered Circle One Dog Cat Bird Other Birthday Color Weight Previous Medical Problems: Allergies to Medications: Other: 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 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 diet Vegetables % of diet Fruit % of diet Pellets % of diet What 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 and please text a video or photo to (949)770-9015Is 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? Yes No When did it start? Do you give your bird any supplements? Yes No What kind? Has your bird received any medications recently? Yes No If yes, please list them:Has your bird had any blood, culture, or fecal tests? Yes No Any recent changes to your home or your bird's environment? Explain:Has quality time or daily routine with your pet changed? Yes No Has your bird traveled anywhere outside the home? Yes No Does your bird have any cage mates? Yes No How many cage mates?If yes, are they showing any signs of illness? Yes No Does your pet spend any time outside (backyard)? Yes No How much time outside? Any sun baths? Has any new birds been added to your aviary or household? Yes No Has your bird boarded/ or been groomed? Yes No If yes, where? Do you have any other questions or concerns? Signature* BOARDING AGREEMENT Today's Date MM slash DD slash YYYY Date of pick-up MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM Owner* Pet's Name #1* Bathe Yes No Clip Yes No Trim Yes No Pet's Name #2 Bathe Yes No Clip Yes No Trim Yes No Pet's Name #3 Bathe Yes No Clip Yes No Trim Yes No Person(s) to contact in case of emergency Telephone number(s)Special Instructions - include detailed medication directions, feeding instructions, etc.VACCINATION POLICY To insure the protection of all pets under our care, the following must be up-to-date: Dogs Cats Birds Annual Exam DHPP Bordetella Rabies Canine Influenza Leptospirosis Fecal O&P + Giardia Annual Exam FVRCP Rabies Fecal O&P + Giardia Annual Exam Viral Screening (Psittacosis, Polyoma, PBFD) Fecal O&P + Giardia If 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 (Capstar or Frontline) at the owner's expense. If not up to date, or unable to provide proof of vaccination, I give permission to update my pet(s) vaccinations in accordance with the above policy. Sign below.In addition, if any fleas/ticks are observed on you pet(s) while boarding, he/she (they) will receive treatment (Capstar) at the owner’s expense. Sign below.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 Treat what is needed (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 Muirlands Animal & Avian Hospital of a new pick-up date. I understand that Muirlands Animal & Avian Hospital will use every reasonable precaution to assure my pets safety while in their care but will not hold the hospital responsible. I understand that Muirlands Animal & Avian Hospital does not have 24-hour staffing and my pet will not be monitored overnight. If my pet is not picked up within two weeks of the arranged date, or otherwise notified we may assume he/she to be abandoned and proceed as legal with the animal abandoned law acts of California State. I hereby authorized to pick up my pet/pets in case I am not available (payment/picture ID required) Signature* Date* MM slash DD slash YYYY Special Instructions: Provide my pet the following food option: Clinic Food Brought food for my pet I brought my own food. Please list the food name below. (Name of food) *Owner will be required to provide canned food or any special dietary preferences, no raw diets or cannabis products accepted in hospital.For the food you brought - please select the type of foodWetDryBothDid you already feed for the day? Yes No How much do you feed? How often do you feed? 1x a day, 2x a day, all day Amount given/ any other special instructions? Meds: My pet has medications to be given during boarding.* Yes No Name of Medication How many? What time? Do you give medication with food or treats? Yes No Were medications already given? Yes No Any other special instructions? Bathing & Grooming (Optional): Please select additional services for your pet Nail Trim Bath w/ Haircut Bath Anal Gland Expression Signature*
