PLEASE PRINT AND COMPLETE THIS FORM THEN SUBMIT IT TO THE CLINIC  BY DROPPING IT OFF AT THE FRONT DESK, FAXING IT (403-249-8160), OR SCAN AND EMAIL TO US (caepcmail@gmail.com).


I, (name)                                                                                           , will be away from

(date of departure)                               to (date of return)                                           .


My pet(s) will be cared for by a pet sitter during my absence.


Name and species of pet(s):                                                                                                                                 


Name of pet sitter:                                                                                                                                                 


Pet sitter's phone number:                                                                                                                                     


Should it be necessary, the above named individual is permitted to make medical decisions regarding my pet if I am unable to be reached respecting financial considerations listed below (circle one):     YES         NO


I authorize Calgary Avian & Exotic Pet Clinic to discuss current medical concerns or treatment plans with the above named individual during my absence (circle one):     YES          NO


During my absence, should my pet require veterinary attention, I request that my pet be treated by the veterinarians at Calgary Avian & Exotic Pet Clinic.


               ( )  My pet sitter will pay for services rendered.

             

               ( )  I will leave my credit card information on file for the duration of my absence and any procedures                        performed may be processed at the time of service. (Please call the clinic to provide credit card                          information)


 In the event that veterinary care is administered to your pet, every attempt will be made to reach you at the contact numbers you have left below.  However, in the event that you can not be reached, please indicate which course of action you would like us to take (please select one option):

             

               ( )  I authorize you to proceed up to $125


               ( )  I authorize you to proceed up to $500


               ( )  I authorize you to proceed up to $1500


               ( )  I authorize you to proceed up to (indicate dollar amount)                                            


               ( )  I authorize you to perform any treatment regardless of cost


               ( )  Please do not perform any procedures for which I am financially responsible


My contact phone number while away:                                                                           


My contact email:                                                                                                           


Signature: