Absentee Owner / Vacation Consent to Treatment Form

Owner: Please fill out this form, print, and sign it, then give it to your pet’s Acting Agent. Keep a second copy for your own records.

I, the owner, do give my permission to the DVMs at Fort Street Veterinarian to perform services on the named animals in my absence if my Acting Agent should contact Fort Street Veterinarian for any of my animals requiring veterinary care. If the emergency is severe, the veterinarians at Fort Street Veterinarian in conjunction with the listed Acting Agent may use their best judgement in determining if my pet(s) can be saved within a reasonable medical probability and financial practicality with a cost cap listed below.

By signing this document I agree to assume all financial responsibility for these services and consent to leaving my credit card information with the Acting Agent. I understand that payments for my pet(s) veterinary services not placed on my credit card will be reimbursed to the Acting Agent, not to Fort Street Veterinarian. If Fort Street Veterinarian’s veterinarians determine that my pet cannot be saved due to the severity of the condition and/or financial constraints, I hereby authorize them to euthanize my pet for humane reasons.

Acting Agent: Bring this form and valid payment with you to Fort Street Veterinarian.