Heartland Kennels
366 5th Line North
Oro-Medonate, ON
L0L 2E0
(705) 487-2660
Veterinary Authorization
____________________
(date)
Dear
Dr. _________________________ and staff of __________________________________,
(veterinarian) (clinic name)
This letter is to advise you that I, __________________________, have retained the services of Heartland Kennels for the care of my pet(s):
For the duration of my absence during the period from _______________ to ______________
(dd/mm/yyyy) (dd/mm/yyyy)
Or
On an ongoing basis. In the event of an illness or injury with my pet(s), I authorize Heartland Kennels to obtain medical treatment at your facility. I have provided Heartland Kennels with an Authorization for Veterinary Services.
Treatment may include, but is not limited to assessment, diagnostic tests, medications and procedures, which are deemed urgent or emergent. I ask that any and all charges associated with your treatment be billed directly to me and have included my client information below.
Client Name: ________________________________ Pet Name(s): _______________________
Address: _________________________________________________ Postal Code: __________
Home Phone: ________________________
Heartland Kennels has my emergency contact information and will be contacting me in the event of an emergency. Please do not hesitate to do so yourself if you require any further information.
Thank you,
Advanced Directives for Care Owner
Name:
Address:
Postal Code:
Home Phone:
Office Phone:
Mobile Phone:
Emergency Contact:
Phone:
E-Mail:
Veterinarian
Name:
Phone:
Address:
Account Holder:
366 5th Line North
Oro-Medonate, ON
L0L 2E0
(705) 487-2660
Veterinary Authorization
____________________
(date)
Dear
Dr. _________________________ and staff of __________________________________,
(veterinarian) (clinic name)
This letter is to advise you that I, __________________________, have retained the services of Heartland Kennels for the care of my pet(s):
For the duration of my absence during the period from _______________ to ______________
(dd/mm/yyyy) (dd/mm/yyyy)
Or
On an ongoing basis. In the event of an illness or injury with my pet(s), I authorize Heartland Kennels to obtain medical treatment at your facility. I have provided Heartland Kennels with an Authorization for Veterinary Services.
Treatment may include, but is not limited to assessment, diagnostic tests, medications and procedures, which are deemed urgent or emergent. I ask that any and all charges associated with your treatment be billed directly to me and have included my client information below.
Client Name: ________________________________ Pet Name(s): _______________________
Address: _________________________________________________ Postal Code: __________
Home Phone: ________________________
Heartland Kennels has my emergency contact information and will be contacting me in the event of an emergency. Please do not hesitate to do so yourself if you require any further information.
Thank you,
Advanced Directives for Care Owner
Name:
Address:
Postal Code:
Home Phone:
Office Phone:
Mobile Phone:
Emergency Contact:
Phone:
E-Mail:
Veterinarian
Name:
Phone:
Address:
Account Holder:
