Absent Owner Treatment Consent Form

Absent Owner Treatment Consent Form
Primary Owner Name

First NameLast Name
Primary Phone Number

Area CodePhone Number
Secondary Owner Name

First NameLast Name
Secondary Phone Number

Area CodePhone Number
Owner Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Departure Date

MonthDayYear
Date
Return Date

MonthDayYear
Date
Primary contact number while you are away

Area CodePhone Number
Secondary contact number while you are away

Area CodePhone Number
Information about the person(s) taking care of your pet while you are away:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Please select one of the following options

The agent above is responsible for my pet while I am away and will be able to make all decisions regarding veterinary careThe agent stated above is responsible for my pet while I am away. For decisions regarding veterinary care, I wish to be contacted. If I cannot be reached, I appoint the following person to act on my behalf:
Name of responsible partyblanks
Phone number of resposible partyblank
Description of your pet:
Pet Name:blanks Species: Breed: blank
Sex: Spayed/Neutered: Age:Type a labelColor: blank
Medical History: (Don't forget to include any medications that your pet may be currently taking)
Should be Empty: