A La Carte, LLC Veterinary Treatment AuthorizationThis form will be retained on file and will be used to authorize veterinary treatment in the event that your pet(s) require treatment during your absence, while in our care, and we are unable to contact you at the time. Should you change veterinarians please notify A la Carte, LLC before service dates. This form MUST be signed to authorize treatment. Name: ____________________________________________________________________ Address: ___________________________________________________________________ City: __________________________________________________ ZIP: ________________ Home phone: _________________________ Work phone: __________________________ Cell/Pager: ___________________________ Other: _______________________________ To whom it may concern: During my absence a representative of A la Carte, LLC will be caring for my pet(s). I give A la Carte, LLC my permission to transport my pets to my veterinarian (or to an emergency clinic). In the event I cannot be reached I authorize A la Carte, LLC to act as an agent on my behalf regarding my pets’ medical care. 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 _____________________________________________ $_____________ _____________________________________________ $_____________ _____________________________________________ $_____________ Veterinary Clinic: _____________________________________________________________ Address: ___________________________________________________________________ City: ________________________________________ Zip Code: ______________________ Phone: ______________________________________ After hours and weekends: (Emergency Clinic Name and Location) I authorize veterinary treatment my animal(s) during my absence. I understand that A la Carte, LLC assumes no responsibility for the loss of any pet and is released from all liability related to transportation, treatment and expense. I have made advance arrangements with your office to pay all charges and fees that are incurred on my behalf, immediately upon my return. Signed _______________________________________________________________________________ M/C Visa Other _____ Name on card: _________________________________________________ Card number & exp date :________________________________________________________________ Maximum charge authorized for veterinary care only _________________________________________ Signed ______________________________________________________________________________ |