Permission to Treat/ Pet Care Consent

Permission to Treat/ Pet Care Consent
Pet Owner(s) Information
Today's Date:*

MonthDayYear
Date
Name:*

First NameLast Name
Email:*
Pet's Name(s):*
Primary Phone Number:*
Please enter a valid phone number.
Secondary Phone Number:
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Expected Date(s) of Absense:*
Pet Sitter/ Care Taker Information

The questions below pertain to the individual who will be caring for the animals listed above.
Caretaker's Name:*

First NameLast Name
Caretaker's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Caretaker's Primary Phone Number:*
Please enter a valid phone number.
Caretaker's Secondary Phone Number:
Please enter a valid phone number.
I, the owner of the above-named pet(s), request that the above pet sitting caretaker feed, exercise, groom, and provide routine care for my pet(s) while i am away from home per my oral or written instructions. Should an injury or illness occur to my pet(s) that requires veterinary care during my absense, I authorize the pet sitter to act as my agent in procuring veterinary care, we request that fees not exceed:
Amount:*
In case of an emergency and/or urgent care appointment, will the caretaker have access to payment options (i.e. credit/debit card, care credit, etc.) while you're away? If so, do they have your permission and authorization to pay for the services provided?

He/she will have access to payment and has permission to pay for services.He/she will not have access to payment and does not have permission to pay for services.Please call the primary phone number on file to collect payment.
I agree to pay the fees for such professional veterinary services as soon as possible after I return and, in the absence of gross negligence, will not hold the pet sitter liable for injuries or illnesses suffered by my pet(s) or any fees for veterinary services incurred on their behalf.
The address and phone number(s) where an authorized agent of mine or I may be reached are:
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add another authorized agent?*

YesNo
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you, or do you not authorize intensive medical care efforts for your pet(s)?*

I do authorizeI do not authorize
My veterinary practice of choice is:*
In the event the attending veterinary determines that your pet is suffering and/or is incurably injured, do you give your consent for euthanasia?*

I give my consentI do not give my consent
If your pet should pass away or is euthanized, please select from the following options:*

I request that the body be retained until I return (I agree to pay the fees for services)I request that the body be individually cremated with ashes returned to myself (I agree to pay the fees for services)I request that the body be communally cremated (I agree to pay the fees for services)
By signing and submitting this form, I agree that all the above information is true and that this submission qualifies as my electronic agreement.*

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Permission to Treat/ Pet Care Consent

Pet Owner(s) Information

Pet Sitter/ Care Taker Information