Emerson
Animal Hospital Absent Owner Form
This is to be
filled out by the owner and used in case their pet(s) needs
emergency care at Emerson Animal Hospital while the pet(s) are in
the care of another person.
Date_____________________________
Client Name:
____________________________________________________
Contact Phone
Number while you are away: (____)_____-_________________
Cell:(____)_____-______________
Pager:(____)_____-_________________
Departure Date
___________________ Returning Date____________________
Person(s) taking care of pet during my
absence:
Name
_______________________________________________________
Telephone
Numbers (please include area code):
Home:(____)_____-______________
Work:(____)_____-_____________
Cell:(____)_____-______________
Pager:(____)_____-_____________
Staying at my
residence?
Yes No
If no, address
_________________________________________________
Please check 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.
PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES
ARE PERFORMED
How will
you be making payment today?* Sorry, we DO
NOT charge!
Cash ___
Check ___ Visa ___ M/C ___ Discover ___ American Ex.
___
* In admitting my pet(s) for diagnostics,
treatment, or surgery, I authorize the veterinarians of Emerson
Animal Hospital, and their support staff, to administer such
treatment and/or perform such diagnostic or surgical procedures as
deemed necessary.
* No guarantee or assurance can be made as to the
results that may be obtained.
* Further, I understand that a deposit of 50% is
required before services are performed and I assume full financial
responsibility for all charges incurred by my pet. I realize that
these charges may exceed a given estimate if complications arise. I
understand that I will be contacted prior to treatment, if
possible, should complications occur.
* I understand that I am personally financially
responsible for all services rendered by the doctors and staff of
Emerson Animal Hospital and that payment is due on the date
performed.
*Issuers of bad checks and persons attempting
theft of services will be prosecuted to the full extent of the
law.
I authorize the use
of my credit card number to be used only while I am away (see the
dates above) by Emerson Animal Hospital to pay for any medical
expenses that my pet(s) 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.
I authorize a
maximum of $______________ to be used towards my pets care at
Emerson Animal Hospital.
Visa or MasterCard
Number: __________________________ Exp. Date: __________
Name (as it appears
on the card) ____________________________________________
Cardholders
Signature
____________________________________________________
Description of pet:
Name:
____________________________ Birth date:_________________
Sex: ___ Female ___
Spayed female ___ Male ___ Neutered male ____ Unknown
Species (eg. cat,
dog)___________ Breed: _______________________________
Vaccination History
_________________________________________
Medical History -
(Don't forget to mention any medications your pet may be currently
taking)____________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Description of pet:
Name:
_______________________________ Birth date:
__________________
Sex: ___ Female ___
Spayed female ___ Male ___ Neutered male ___ Unknown
Species (eg. cat,
dog): ___________ Breed: ______________________________
Vaccination History
_________________________________________
Medical History -
(Don't forget to mention any medications your pet may be currently
taking)____________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
