Longenbaugh Veterinary Hospital

 

 

 

If you wish for more than one person to have the right to sign authorization forms or make payment for services for your pet, this person must be listed in our records as a co-owner or agent of owner. You may use this form to add the name to your records.

You can print the form and bring it with you or you may submit the form directly from our website. By submitting a form directly from our website, you are agreeing that the form will serve as a signed form.  Thank you.  If you have any questions, please call us at 281-856-7023.                                                                            

 


Only an owner , co-owner, or agent of owner may authorize services or make payment for services for a pet. Please fill in the spaces below for our records.
*Pet's Name
*Owner's name
*Agent of Owner Name

As owner of this pet, I give my permission to the agent listed above to authorize services and make payment for services for my pet. I understand that I am responsible for all charges for services including those authorized by my agent.

I understand that this submitted form will serve as my signature as the owner of this pet.
*Date