Absent Owner Treatment Consent Form

Absent Owner Treatment Consent Form
Owner name
First NameLast Name
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Owner email
example@example.com
List your pet(s)
Departure date and time
MonthDayYear
Date
Hour MinutesAM/PM Option
Return date and time
MonthDayYear
Date
Hour MinutesAM/PM Option
Authorized agent name
Authorized agent address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Choose one of the following statements for the cases of your pet's veterinary care
In case, you are not reached out, list the contact person(s)
Choose one of the following statements for the financial needs of the treatments
Maximum amount of money you authorize
1. I, the owner of the above-listed animal(s), agree to assume a {chooseOne16} responsibility for these services. I will pay the agent at the time of service with a credit card over the phone.

2. I confirm that all the information given in the form is correct and understand that if decisions need to be made or procedures need to be performed in my absence, this form will be used to make decisions.
Signature
Clear
Should be Empty: