AUTHORIZATION TO PROVIDE TREATMENT

AUTHORIZATION TO PROVIDE MEDICAL TREATMENT
Owner*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Telephone #: (While away)*
Format: (000) 000-0000.
Alternate Telephone #
Format: (000) 000-0000.
Animal Name(s)
Animal's Name #2
Name of Caregiver(s)
Contact # for caregiver
Name of authorized contact person if not the caregiver
Contact # of Authorized person if not the caregiver
Please enter a valid phone number.Format: (000) 000-0000.
Date you will be leaving

MonthDayYear
Date
Date you will return

MonthDayYear
Date
I am the owner of the above mentioned animal(s) In the event that my pet(s) should require medical treatments during my absence, I understand that reasonable efforts will be made to contact me, or my authorized contact person, to discuss medical situation and recommendations. However, if the efforts are unsuccessful, I authorize the performance of any procedures or treatments deemed necessary in the professional opinion of the attending veterinarian.
Date

MonthDayYear
Date
Owner
Witness
Please note, that payment for services is due at the time they are rendered.
It may be helpful to plan for this in advance with your authorized caregiver.
Signature of Owner
Should be Empty: