Annual ownership and consent form

Consent is valid only when given by a person who has the legal authority to give consent for the animal. It is important to note that any significant changes to the client identification records requires the consent of all listed owners. This includes instances in which one owner requests the removal of another owner from the medical record.

Owner’s name*
The owner is the person with whom we will interact with to discuss health care for the patient. An owner must be 18 years of age or older and cannot be appointed by someone else. The owner is responsible for all health, financial, and end-of-life decisions.
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Home phone*
Cell phone*
Work phone
Email*
Permission to transmit personal information via email:*
- Yes
- No
Co-owner’s name
The co-owner has agreed to be designated as such and has complete authority in making health, financial, and end-of-life decisions. The co-owner is preferably someone who resides at the same address as the owner and must be 18 years of age or older. The co-owner must have the ability to answer all questions regarding the pet's health. If the person assigned co-owner today is different than the co-owner currently listed on your pet's file, our team will contact you to discuss this further. THE CO-OWNER'S NAME CANNOT BE REMOVED FROM THE FILE WITHOUT THEIR EXPRESSED CONSENT TO DO SO.
First Last
Address
Street Address Address Line 2 City Province Postal Code
Home phone
Cell phone
Work phone
Email
Permission to transmit personal information via email:
- Yes
- No
Authorized representative (1) contact information
An authorized agent is a person authorized by the owner(s) to act on their behalf and whose decisions bind the owner as though they were themselves making the decisions. The authorized agent MUST be 18 years of age or older.
First Last
Address
If different than owner

Street Address Address Line 2 City Province Postal Code
Cell phone
Authorized representative (2) contact information
First Last
Address
If different than owner

Street Address Address Line 2 City Province Postal Code
Cell phone
Financial amount authorized. If I am unavailable, my authorized representative(s) is/are authorized to:
1-Make financial decisions on my behalf up to (enter financial amount below)
Treatments authorized. If I am unavailable, my authorized representative(s) is authorized to:
2- Make the following medical decisions on my behalf:

HOURS OF OPERATION

Monday	8:00am – 5:00pm
Tuesday	8:00am – 5:00pm
Wednesday	8:00am – 5:00pm
Thursday	8:00am – 5:00pm
Friday	8:00am – 5:00pm
Saturday	Closed
Sunday	Closed

For all after hours emergencies please contact:

Smart.Vet: (virtual care) 647-695-5411

Alta Vista Animal Hospital: 613-731-6851

Ottawa Veterinary Hospital:
accepting emergencies from 10am – 10pm 613-725-1182

Ottawa Animal Emergency Specialty Hospital:

613-745-0123

Annual ownership and consent form

HOURS OF OPERATION

CONTACT US