Forms
PupStars Pet Care Veterinary Treatment Authorization
This 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 PupStars Pet Care 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 PupStars Pet Care will be caring for my
pet(s). I give PupStars Pet Care my permission to transport my pets to my veterinarian (or to an emergency
clinic). In the event I cannot be reached I authorize PupStars Pet Care 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
PupStars Pet Care reserves the right to utilize the services of any available veterinary clinic. If time permits,
we will attempt to utilize your primary veterinary clinic. If it is not practical to do so, the following information
will be helpful if the clinic we utilize requires documentation from your primary clinic.
Veterinary Clinic:
Address: City:
Zip Code: Phone:
After hours and weekends: Chicago Veterinary Emergency Services
3123 N. Clybourn Ave.
Chicago IL, 60618
773-281-7110
I authorize veterinary treatment my animal(s) during my absence. I understand that PupStars Pet Care
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.
Name:
OR: M/C Visa Other Name on card:
Card number: Exp date :
Maximum charge authorized for veterinary care only:
Authorization Name:
