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:*

The Pet Caretaker designated above is responsible for my pet(s) while I am away and is authorized to seek veterinary services and to make all medical decisions regarding veterinary care in my absence.I wish to be contacted for medical decisions regarding veterinary care. If I cannot be reached, the designated caretaker will make treatment decisions on my behalf.I wish to be contacted for medical decisions regarding veterinary care. If I cannot be reached no action will be taken.
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 any amount necessary for the treatment of my pet. Must have VALID credit card on file.I authorize no more than the amount listed below to be used towards my pet’s care. Must have VALID credit card on file.
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*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Pet Caretaker Treatment Authorization