Owner’s name(s):                                                                                                                 

The following individual(s) :

Caretaker: _______________________________________

Caretaker: _______________________________________

have my permission to bring my pets _________________________________

to Briar Patch for any treatment needed while I am (we are) out of town.  I (We)

will be gone from ______________________to _________________________. 

I (we) can be reached for major medical decisions:

By phone                                                                                                       

And/or by email                                                                                            

All minor medical decisions can be made by the above named individual(s)

SPECIAL INSTRUCTIONS:

PAYMENT ARRANGEMENTS:

(  ) Please charge my credit card for the cost of treatment up to  $___________

Credit card #                                                                     Expiration date:_________

(VISA/MC/DISCOVER/AMEX)

(  ) Bill my account (For clients in good standing, only)

___________________________________                                     ___________

Signature                                                                                           Date