Veterinarian Authorization – Upper Valley Pet Care LLC

It is very important this form is accurate and up to date for our files. Please fill out ONE FORM PER EACH PET.

Application Date (MM/DD/YYYY): *

This form will be retained on file and will be used to authorize urgent veterinary treatment in the event that your pet(s) requires such treatment during your absence. The lower portion is in the event your veterinarian is unavailable and/or we are unable to contact you for other instructions.

Should you change your veterinarian please notify us as soon as possible.

Pet's Name: *

Client's Name: *

First

Last

Name of Veterinarian(s): *

Name of Veterinarian Practice/Clinic/Hospital: *

Veterinarian's Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Veterinarian's Phone #: *

I authorize you to treat my animal(s) and I will be fully responsible for all fees and charges and will pay for all charges incurred on my behalf upon my return. I further authorize you to give out any information about my animal(s) to Upper Valley Pet Care, L.L.C as needed.

Client Signature: *

Please type your full name.

Date / Time: *

Date

Time

EMERGENCY Veterinary Authorization:

This form will be retained on file and will be used to authorize emergency treatment only in the event that your pet(s) require such treatment during your absence and your veterinarian is unavailable and/or we are unable to contact you at the time.

Client Name: *

First

Last

Cell #: *

Email: *

To whom it may concern: I have contracted for services from Upper Valley Pet Care, L.L.C. during my absence and authorize them to act on my behalf to request emergency veterinary treatment and services if deemed necessary.

I accept full responsibility for charges incurred in the treatment of my pet(s): *

Please list pet(s) names

Date / Time: *

Date

Time

Special Instructions:

Upper Valley Pet Care, L.L.C. reserves the right to utilize the services of any available veterinary clinic in case of an emergency. I authorize you to treat my animal(s) and I will be fully responsible for all fees and charges and will pay for all charges incurred on my behalf upon my return. I further authorize you to give out any information about my animal(s) to Upper Valley Pet Care, L.L.C. as needed.

Client Signature: *

Please type your full name.

Phone