Caretaker Treatment Authorization Form

Pet Caretaker Treatment Authorization
Owner Name

First NameLast Name
Phone Number

Area CodePhone Number
This Authorization is valid from: Date to Date .
Designated Caretaker(s):
First Name Last Name Area Code Phone Number
First Name Last Name Area Code Phone Number
Pet Name #1
Pet Name #2
Please check one of the following statements:
West Coast Animal Hospital will make every attempt to reach the pet owner in the event that their pet(s) require medical care.
Finances
Please Check The Following:
I authorize no more than $dollar amount to be charged to my card.

*All payments must be made at the time services are rendered.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Pet Caretaker Treatment Authorization