CritterCare PLUS
VETERINARY SERVICE AUTHORIATION
Regular Veterinarian_____________________________________________________________________________
Pets Name/Names______________________________________________________________________________
In my absence, CritterCare PLUS will be caring for my animal(s). CC+ has
my permission to transport them to and from your office or, in the case of
large animals, request "on site" treatment from your office as is
deemed necessary. I authorize you to treat my animal(s) and I will be fully
responsible for all fees and charges incurred on my pet(s) behalf when I
return. I further authorize you to give out any necessary information about my
animal(s) to Melinda Stone, the owner of CritterCare PLUS.
Client Signature_______________________________________________________________________
Urgent Veterinary Treatment Authorization
This form will be retained on file and will be used to authorize urgent
veterinary treatment in the event that your pet(s) require such treatment during
your absence and we are unable to contact you at the time. Should you change Vets please notify CCP
before service dates.
Client Name:_________________________________________________________________________
Address:____________________________________________________________________________
City:
____________________________________________________________ZIP:________________
Home Telephone:
__________________Work Telephone: ______________Mobile: ________________
Primary (other) Emergency Contact:
_____________________________________________________________
Alternate Emergency Contact:__________________________________________________________________
To whom it may concern: I have contracted for services from CritterCare
PLUS during my absence and I authorize CritterCare PLUS to act on my behalf to
request veterinary treatment and services when they deem it necessary. I accept
full responsibility for charges incurred in the treatment of my pet(s), not to
exceed the following amounts for each pet:
Pet Name- Description- Maximum Amount
_____________________________________________________________________$_____________
_____________________________________________________________________$_____________
_____________________________________________________________________$_____________
_____________________________________________________________________$_____________
_____________________________________________________________________$_____________
If multiple pets require treatment, do not exceed a combined total of
$_________________.
Special
Instructions:
_____________________________________________________________________________________
CritterCare PLUS reserves the right to utilize the services of any
available veterinary clinic. If time permits, we will attempt to utilize your
primary veterinary clinic. If it is not practical to do so, CritterCare PLUS is
authorized to utilize an alternative Veterinarian or Emergency Facility and in
the case of larger animals, may find it necessary to utilize an animal
ambulance service to transport animals to the veterinary clinic. In the unlikely event that a pet has passed
on, CritterCare PLUS is authorized to transport the pet to the veterinary
clinic to be held under refrigeration until owner can be contacted regarding
disposition.
I authorize you to treat my animal(s) and I will be fully responsible for
all fees and charges and will pay for all charges that are incurred on my
behalf, immediately upon my return. Credit
Card to use if I cannot be reached: Name_________________________________ Type
Card: ______________________________________
#____________________________________ Billing Zip Code::
__________________________________
Expiration: ____________________________
Max. Charge Authorized____________________________
Authorized charges to this card are for Emergency Veterinarian
Services/Pet Medications ONLY.
______________________________________________________________________________________
Client Date