Temporary Caretaker Authorization

OWNER NAME

PHONE NUMBER

CARETAKER NAME

PHONE NUMBER

NAME OF PET(S)

DATES OF EXPECTED ABSENCE: FROM

DATES OF EXPECTED ABSENCE: TO

Please check one of the following statements

I authorize the caretaker named above to bring my pets in for veterinary care and to make all decision regarding veterinary care in my absence

I authorize the caretaker named above to bring in my pets for veterinary care, but I want to be contacted for all treatment authorization. If I cannot be reached, I authorize

NAME

PHONE #

FINANCES: Payment is due at the time of service. Please check one of the following statements:

The caretaker named above will provide payment at the time of service.

I will provide payment via credit card over the phone.

OWNER SIGNATURE

Sign above

DATE

Temporary Caretaker Authorization

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