Owner Name* First Last Phone Number*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Departure Date* MM slash DD slash YYYY Return Date* MM slash DD slash YYYY Contact Phone Number while you are away:*Person taking care of pet during absence First Last PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please select one of the following statements:* The agent above is responsible for my pet(s) while I am away and will be able to make all decisions regarding veterinary care. The agent stated above is responsible for my pet(s) while I am away. For decisions regarding veterinary care, I wish to be contacted. If I cannot be reached, I appoint the following person to act on my behalf:Name* First Last Phone*FINANCES:I authorize the use of my card number to be used only while I am away (see the dates above), by the above stated veterinary hospital to pay for any medical expenses that my pet(s), listed on page 2, may require. I am aware that my credit card number will be kept on file but will be stored in a private and confidential manner. Please check one of the following:* I authorize any amount necessary for the treatment of my pet at stated hospital. I authorize a maximum of $______________ to be used towards my pets’ care at stated hospital.Maximum amount:*Owner Signature:*Date* MM slash DD slash YYYY Description of pet 1Name*Birth date* MM slash DD slash YYYY Sex* Female Spayed female Male Neutered maleBreed*Medical History (Don’t forget to mention any medications your pet may be currently taking):*Add another pet?* Yes NoDescription of pet 2Name*Birth date* MM slash DD slash YYYY Sex* Female Spayed female Male Neutered maleBreed*Medical History (Don’t forget to mention any medications your pet may be currently taking):*Add a third pet?* Yes NoDescription of pet 3Name*Birth date* MM slash DD slash YYYY Sex* Female Spayed female Male Neutered maleBreed*Medical History (Don’t forget to mention any medications your pet may be currently taking):*Add a fourth pet?* Yes NoDescription of pet 4Name*Birth date* MM slash DD slash YYYY Sex* Female Spayed female Male Neutered maleBreed*Medical History (Don’t forget to mention any medications your pet may be currently taking):*PhoneThis field is for validation purposes and should be left unchanged.
