Owner Absence Form

Name

Address

Email Address

Contact Number

Alternate Contact Number

As the owner of this animal, I give permission to:

to bring my animal to Wauconda Animal Hospital for treatment and/or non-elective surgery if indicated during my absence (dates listed below) up to the amount of $

In the event of a terminal illness or at the discretion and concurrence of both the doctor and the responsible party named above, I also give permission for euthanasia and disposal. My wishes in such case are:

Communal Cremation

Private Cremation (Cremains Returned)

This permission form is valid from:

Pet's Name

Species

Age

Sex

Male

Female

Spayed/Neutered

Color

Breed

to:

I will be responsible for any charges incurred:

I have left a check with the above designated responsible party to cover any incurred charges.

Please charge my credit card, on file, up to the amount stated above.