Owner’s Name *

First

Last

Owner Availability While Away

Will you be reachable during your trip? *

Yes
Limited
No

Preferred method of contact while away: *

Phone
Text
Email

Alternate contact number while away (if different):

Date Of Absence

From *

To *

Prefered Contact Number *

Email *

Caretaker’s Full Name *

First

Last

Caretaker’s Phone Number *

Name/Address of Boarding Facility *

Medical Decision-Making Authority

Does the caretaker/pet sitter have permission to make medical decisions on your behalf if you cannot be reached? *

Yes
No

Name of person authorized to make medical decisions: *

Relationship to pet: *

Phone *

Email *

(Optional but helpful) Is there a maximum dollar amount you authorize for treatment without direct approval? *

Emergency Preferences

In an emergency, do you authorize the clinic to provide immediate treatment deemed necessary to relieve pain or prevent suffering if we cannot reach you? *

Yes
No

Do you have any specific instructions or limitations regarding emergency care? *

Financial Authorization

Payment responsibility while you are away: *

Credit card on file (owner)
Caretaker/pet sitter responsible for payment

(If you do not already have a card on file please call to add this before you leave)

Acknowledgement & Consent

I confirm that the information provided above is accurate and authorize the clinic to rely on it for the duration of my absence. *

I Agree and Understand

(If you do not already have a card on file please call to add this before you leave)

Owner Signature (digital) *

Date *

Authorization In Owners Absence Form

Owner Availability While Away

Date Of Absence

Medical Decision-Making Authority

Emergency Preferences

Financial Authorization

Acknowledgement & Consent

Make An Appointment

Have a Question?

Contact Information

Location

Hours

Associated Clinics

Bronte Village Animal Hospital

Mobility Matters Pet Rehabilitation

We proudly serve the pets of Brantford and beyond.

Burford

Brantford

Paris