“While I’m Away”

If you would like to authorize an individual(s)/agent(s), on your behalf, to proceed with any medical treatment necessary for the well-being of your animal(s) in your absence, please fill out the form below.

Your Name (Owner)

First Name

Last Name

Your Email

Beginning Date

YYYY

Ending Date

YYYY

Name of person to authorize treatment on your behalf

First Name

Last Name

Phone Number of Authorized Person

(###)

###

####

Name or any other person to authorize treatment on your behalf

First Name

Last Name

Phone Number of Authorized Person

(###)

###

####

Address location of your animal(s).

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Animal(s) Name(s)

Species

Horse

Goat/Sheep/Alpaca

Pig

Please add any instructions:

By submitting this form below, you are authorizing the individual(s), aka agent, to act on your behalf with the care of your animal(s) listed on this form, in the event that you are unable to be reached. You are giving permission for your agent to proceed with any medical treatment necessary for the well-being of your animal(s). By submitting this form, you also agree that you will be responsible for any and all veterinary costs incurred for the care of your animal(s) that have been initiated by you and/or agent.