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Pet Care Authorization Form

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Pet Care Authorization Form

Owner Information

Owner Name *

First

Last

Phone Number *

Email Address *

Pet Information

Pet Name(s) *

Species/Breed *

Authorized Caregiver Information

I authorize the following person(s) to make medical and financial decisions regarding my pet(s) while I am away. Authorized Caregiver Name: *

First

Last

Relationship to Owner: *

Phone Number *

Email Address *

Authorization

Special instructions or medical concerns:

I, the undersigned owner or authorized agent of the pet listed in this record, hereby authorize the designated pet sitter/caregiver to seek veterinary care for my pet at East Rockaway Veterinary Hospital and to make medical decisions regarding my pet’s care and treatment during the period of my absence or unavailability. *

I agree and understand

I authorize the veterinarians and staff of East Rockaway Veterinary Hospital to examine, treat, prescribe medication for, hospitalize, anesthetize, and/or perform emergency procedures for my pet as deemed medically necessary for the pet’s health and well-being, based on the consent of the designated pet sitter/caregiver. *

I agree and understand

The designated pet sitter/caregiver shall have full authority to approve recommended diagnostics, treatments, medications, procedures, and emergency care on my behalf. I understand that all reasonable medical decisions may be made directly with the designated pet sitter/caregiver without the need to contact me prior to treatment. *

I agree and understand

I understand and agree that I remain financially responsible for all veterinary services, treatments, medications, and related charges incurred on behalf of my pet. *

I agree and understand

Signature *

Clear Signature

Date *

Message

Online form

Pet Care Authorization Form

Pet Care Authorization Form

Owner Information

Pet Information

Authorized Caregiver Information

Authorization

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