Emergency Treatment Authorization"*" indicates required fieldsOwner Name* First Last Phone Number*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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):*CAPTCHAEmailThis field is for validation purposes and should be left unchanged.Δ
