Orcas Veterinary Service
Pet Caretaker Consent Form
Your Name:
*
Your Email:
*
Phone:
*
Second Phone Number:
Address:
A phone number where you can be reached during your absence:
*
Your Pets' Names:
*
Caretaker Name:
*
Caretaker Primary Phone:
*
Caretaker Alternate Phone:
Email:
example@example.com
Will you be available by phone and/or email while away?
*
( yes )
No
2nd Phone:
Date of Departure:
/
Month
/
Day
Year
Date
Date of Return:
/
Month
/
Day
Year
Date
If we are unable to contact you, do you have a monetary limit you would like to place on the services your animal may receive? Limit: $
*
Limit: $
In the event that the veterinarian determines the animal is suffering and/or cannot be treated; does your caretake have your authorization to consent to humane euthanasia?
*
Yes
No
Pet Owner Signature:
*
Printed Name:
Date:
/
Month
/
Day
Year
Date
Preview PDF
Submit
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