Absent Owner Consent Form

Morris Animal Hospital

Absent Owner Consent Form
To be filled out by the owner and used in case their pet(s) needs emergency care at Morris Animal Hospital while your pet(s) are in the care of another person.
Owner Name*

First NameLast Name
Email*
example@example.com
Owner Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Departure Date*

MonthDayYear
Date
Return Date*

MonthDayYear
Date
Phone Number*
Alternate Number
Pet Name*

First Name
Pet Name (2)

First Name
Pet Name (3)

First Name
Medical History
Person(s) Taking Care of Pet During Absence*

First NameLast Name
Person(s) Taking Care of Pet During Absence

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please choose one of the following statements:
The agent above is responsible for my pet(s) while I am away and will be able to make all decisions regarding veterinary care.

Yes, I agree.
The agent stated above is responsible for my pet(s) while I am away. For decisions regarding veterinary care, I wish to be contacted. If I cannot be reached, the above person(s) can act on my behalf.

Yes, I agree.
I understand that if my pet(s) need treatment while I am away (see the dates above), that I will incur service fees by the Morris Animal Hospital for medical expenses that my pet(s), listed on page 2, may require. Please check one of the following:
I authorize any amount necessary for the treatment of my pet at Morris Animal Hospital

Yes, I agree.
I authorize a maximum of $______________ to be incurred until I can be reached for further discussion.
By signing below, you are authorizing responsibility for charges for any and all services incurred for your pet(s) while you are away.
Signature*

Clear
DateTime
Should be Empty:

Morris Animal Hospital