Client Absent Form

Please fill this form out for our records if you plan on vacationing and/or be away from your pet for an extended period of time. If an emergency were to occur with your pet it will help us in contacting you and what direction to take.

Owner Name*
First Last
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Departure Date*
MM
DD
YYYY
Returning Date*
MM
DD
YYYY
Contact Phone Number while you are away*
Additional Notes:*
Pet(s) Names*
Names
Current Medications*
Person(s) taking care of my pet during my absence:*
First Last
Pet Sitters Phone Number*
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. If I am not available, I appoint the person listed above to act on my behalf.
PAYMENT METHOD/INFORMATION
I authorize diagnostics and treatment up to a value of $*
I give Shannondale Pet Hospital permission to bill this to my credit card.*
- Visa
- MasterCard
- American Express
Credit Card Number:*
Expiry: V-Code (3 digits on back of card):*
Signature:*
First Last
Date*
MM
DD
YYYY

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Client Absent Form

PAYMENT METHOD/INFORMATION

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