"*" indicates required fields

Owner*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Pet's Name*

Breed*

Age*

Phone Number where owner can be reached*

In Case of Emergency Contact

First Last

Emergency Number

I am the owner of the above named pet and I give Martinez Animal Hospital authorization to treat my pet while I am out of town.

Dates gone*

Person(s) authorized to bring my pet in for treatment*

They are authorized until*

I give Martinez Animal Hospital further authorization to: (Please fill out explaining to what extent you will allow your pet to be treated and if you are willing to have surgery performed if deemed necessary by the veterinarian in charge):*

I am willing to spend up to (please enter a dollar amount for which you will be responsible).*

I give Martinez Animal Hospital authorization to euthanize my pet in the event of an emergency or if treatment would exceed what I have stated above, OR if the animal is suffering and it is the only humane solution to end any prolonged suffering. (owner's signature*

Date*

This form will stay on permanent record or until further notified by the owner.

Phone

This field is for validation purposes and should be left unchanged.

Out Of Town Authorization For Treatment

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