Absent Owner Authorization Form

Owner Information

First name

Last name

Email

Phone

Your pet's information

Your pet(s)'s name

Authorized Caregiver / Pet Sitter

Emergency Contact (in addition to caregiver)

Is this person authorized to make medical decisions if we cannot reach you?

Yes

No

Medical Authorization

While I am away, I authorize the veterinary clinic to provide necessary medical treatment for my pet. Please choose one:

Perform only essential/emergency care if needed

Perform any care needed but contact me first if possible

Perform any care needed even if I cannot be reached

Maximum amount authorized without direct owner approval:

Sedation / Anesthesia Consent

There may be situations where sedation or anesthesia is required for diagnostics, treatment, or to ensure the safety and comfort of your pet and staff.

I authorize the use of sedation/anesthesia for my pet if the veterinarian deems it necessary:

Yes, I consent

No, I do not consent

Yes, but only in urgent/emergency situations if I cannot be reached

I understand that all sedation and anesthesia procedures carry some level of risk. The veterinary team will use their best judgment and standard safety practices.

Billing / Payment

Responsible party for payment during owner’s absence:

Owner

Caregiver

Emergency contact

Visa or MasterCard Number

Expiratory date of your credit

Departure Date:

Return Date:

For your security, any credit card information provided will be cleared from our system seven (7) days after your return date.

Signature

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By signing below, I confirm that the information provided in this form is accurate. I authorize the veterinary clinic and the designated caregiver to make decisions and seek treatment for my pet according to the permissions I have selected. I understand that medical treatments—including sedation or anesthesia, if consented—will be performed in the best interest of my pet’s health and safety.