Fields marked with a * are required.
Pet Owner Name
Pet Caretaker Name
If you are planning on a trip, let us know your expected dates of absence.
Dates of Absence
I, the owner of the above-named pet, request that the caretaker feed, exercise, groom, and provide routine care for my pet per my oral or written instructions while I am away from home. Should an injury or illness occur to my pet(s) that requires veterinary care during my absence, I authorize the caretaker to act as my agent in procuring essential veterinary medical care, with fees not to exceed the following amount. I agree to pay the fees for such professional veterinary services as soon as possible after I return.
Fees not to exceed:
If we need to contact you, an agent, or relative of yours in regards to services that need to be rendered, let us know how to reach you.
Name and Relationship
Email or Phone Number
I authorize a veterinarian to furnish my pet with veterinary care and to provide essential medical services without my consent. Your decision to authorize intensive medical efforts for my pet if authorized below. If authorizing medical care, the dollar amount that should not be exceeded before contacting me is the amount below.
Authorize intensive medical care
I do not
Amount not to exceed for intensive medical care
Contacting your pet’s local veterinarian and making them made aware that you will be absent and that the above caretaker may seek veterinary services in your absence is important. The veterinary practice of my choice for medical care is:
is not aware
Veterinarian Name, Address and Phone Number
In the event the attending veterinarian determines that your pet is suffering and/or is incurably injured, you can choose to give consent for euthanasia. If my pet should die or is euthanized, I can request that the body be retained until you return, be individually cremated, or be communally cremated and you agree to pay the fees for such services.
If my pet should die, I request the body...
be individually cremated
be communally cremated
be retained until I return
I would allow euthanasia
I would not allow euthanasia
By typing your name in the box below and submitting this form, you are giving your consent, according to your preferences above, in regards to care to be given to your pet by your pet caregiver and/or a veterinarian.
Type your full name