Name: Del Mar Veterinary Hospital
Address: 1023 A1A Beach Blvd, Augustine, FL32080
Telephone: +1-(904) 717-0777
Price range: $$

ARE YOU TRAVELING? Going out of town for a few days? Need help caring for your pets?

Absent Owner Consent Form

Authorization for a third party (non-owner) to make medical and financial decisions on behalf of the absent owner.

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About You
Your Full Name:(Required)
First Last
Your Phone Number:(Required)
Your Email Address:
Your Address
Street Address Address Line 2 City ZIP Code
Best Contact Phone Number while you are away:(Required)
Caretaker's Information:
Caretaker Full Name:(Required)
First Last
Caretaker's Phone:(Required)
Caretaker's Email:
Caretaker's Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please check one (1) of the following statements:(Required)
- The caretaker is responsible for my pet(s) while I am away, but I will be able to make ALL the decisions regarding veterinary care, NO exceptions., unless specified otherwise by an additional authorization.
- The caretaker is responsible for my pet(s) while I am away, but for decisions regarding veterinary care, I wish to be contacted. If I cannot be reached, the caretaker is authorized to act on my behalf.
- I understand that in the event of an emergency, time is critical. I give full authorization to Dr. Nieves at Del Mar Veterinary Hosor representing Veterinarian at Manat to make medical decisions in the best interest of my pet in the event of an emergency.
Patient Information:
***Pets authorized for treatment by Del Mar Veterinary Hospital.
Patient #1:(Required)
Species:(Required)
Patient #2:
Species:
Patient #3:
Species:
Patient #4:
Species:
Additional Important Information:
Form's Time Period:
Please confirm the period this form is effective for.
START Date:(Required)
MM slash DD slash YYYY
END Date:(Required)
MM slash DD slash YYYY
FINANCES
I authorize the use of my card number to be used only while I am away (see the dates above), by the above stated veterinary hospital to pay for any medical expenses that my pet(s), may require. I am aware that my credit card number will be kept on file but will be stored in a private and confidential manner.
Please check one (1) of the following statements:(Required)
- I authorize any amount necessary for the treatment of my pet(s) at Del Mar Veterinary Hospital.
- I authorize a maximum (* stated below) to be used towards the care of my pet(s) at Del Mar Veterinary Hospital.
Maximum $ Amount to be used towards the care of my pet(s) at DMVH.(Required)
CREDIT CARD INFORMATION:
VISA | MASTER CARD | DISCOVERY | CHASE | AMEX | CARE CREDIT
Named Cardholder:(Required)
Card Number:(Required)
Expiration Date:(Required)
CVV Code:(Required)
Billing Zip Code:(Required)
Driver's License #:(Required)
State of Issue:(Required)
Additional Comments & Information:
Your (Owner) Signature:(Required)
Date Completed:(Required)
MM slash DD slash YYYY
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Absent Owner Consent Form

ARE YOU TRAVELING? Going out of town for a few days? Need help caring for your pets?

Absent Owner Consent Form

Next Steps: Sync an Email Add-On

About You

Caretaker's Information:

Patient Information:

Form's Time Period:

FINANCES

CREDIT CARD INFORMATION:

Section Break