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Phone

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Pet(s) Name*

I, the undersigned owner of my pet(s) named above certify that I am over the age of eighteen years of age and hereby appoint:*

Name

Address

Phone

as my agent to make all heath care decisions for my pet(s), 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 deterimine the choice I would want for my pet, then my agent's decision shall be based on what he or she believes is in my pet's best interest. This medical power of attorney takes effect if I become unable to make health care decisions for my pet and this fact is certified in writing by me or my physician.

The following sets forth limitations on the decision-making authority of my agent (choose one of the statements below):

I agree to pay for all services my agent authorizes.

I agree to pay for all services my agent authorizes, as long as the fees for my pet's medical care do not exceed

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 this power of attorney. If I am unable to make health care 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 health care decisions for my pet(s).

If the person designated as my agent is unable or unwilling to make health care decisions for my pet, I designate the following alternative person to serve as my agent:

Name

Address

Phone

This power of attorney ends:*

Client Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Signature*

Date*

Medical Power of Attorney

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