I hereby grant permission for   First Name   Last Name  (name of person caring for your pet(s) while you are out of town) to bring in my pet(s)   Pet #1  ,   Pet #2     for medical treatment while I am away. I will be leaving on   Date   and will return on   Date   .

I authorize Four Corners Veterinary Hospital to examine, prescribe for, treat, or perform surgery upon the above-described pet(s), and I will be responsible for all charges incurred.

I give permission to Four Corners Veterinary Hospital to use my credit card number   Credit Card Number   , with an expiration date of   Date   or my last card on file ending in   last 4 digits of card on file   .

Additional comments:      .



     

Signature:   Signature   Date:   Date   

Please print name: First Name   Last Name   

Emergency telephone number where you can be reached at during your time away:   Area Code   Phone Number