Absent Owner Consent for Treatment

1

Owner Name* This field is required.

First Name

Last Name

2

Pet Names:* This field is required.

3

Owner's Contact Information while you are away:* This field is required.

4

Owner's Departure Date:* This field is required.

5

Owner's Return Date:* This field is required.

6

Person(s) taking care of pet(s) during your absence (Caregiver):* This field is required.

7

Caregiver's Contact Information:* This field is required.

8

Please check one of the following statements:* This field is required.

The above named Caregiver is responsible for my pet(s) while I am away and will be able to make any and all decisions regarding veterinary care.

The Caregiver 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 in a timely manner, I request that the Caregiver act on my behalf.

The Caregiver 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 in a timely manner, I request that the examining veterinarian act on my behalf (see next question).

Other

9

Please indicate how would like the doctor to proceed in the event that we are unable to reach you:

Do what he/she feels is medically necessary to treat and diagnose my animal without regard to cost

Do what he/she feels is medically necessary to treat and diagnose my animal not to exceed the dollar amount listed below:

Other

10

Is there anything else you would like us to know?

11

Financial Obligations:* This field is required.I understand that I will be held fully responsible for all charges authorized by my assigned Caregiver. The following payment arrangements have been made.

Caregiver will pay all fees and I (owner) will reimburse them upon my return

I have left a credit card on file at the Animal Clinic of West Plains to be used in the event my pet requires medical care while I am away.

12

I authorize the use of my card number to be used only while I am away (see dates above) by the Animal Clinic of West Plains to pay for any medical expenses that my pet may required. I am aware that my credit card number will be kept on file, but will be stored in a private and confidential manner.

13

Signature of Owner/Agent* This field is required.

Clear

14

Date