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Vacation Consent Form

Name of Pet
Age
Species
- Canine
- Feline
- Other
Sex
- Male
- Female
Spayed/Neutered
- Yes
- No
I will be leaving my above described pet in the care of the following:
Starting on:
Date Format: MM slash DD slash YYYY
Ending on:
Date Format: MM slash DD slash YYYY
If necessary, I authorize the doctors and staff of Londonderry Animal Hospital to commence emergency treatment for my pet. I understand that Londonderry Animal Hospital will attempt to contact me as soon as possible. If I cannot be reached, I authorize the following to make decisions for my pet on my behalf:
- Person(s) listed below
- Doctors of Londonderry Animal Hospital
Name of person (if applicable) to authorize on your behalf:
First Last
Phone
Name of second person (if applicable) to authorize on your behalf:
First Last
Phone
I wish for the doctors and staff to:
- Do whatever is deemed necessary for name of pet's comfort and safety.
- Do NOT EXCEED the following amount without my personal consent.
If applicable, please enter the amount to not exceed without consent:
Phone number where I can be reached during this time:
Additional Comments:
Names of any other pets also included in this consent:

Your Veterinarian in Middletown, PA

Your Other Family Doctor

Our Location

2164 East Harrisburg Pike
Middletown, Pennsylvania, 17057

Contact

Phone: 717-944-5863
Fax: 717-944-2838
Email: info@londonderryvet.com

Hours

Sun: Closed
Mon: 7:30 am – 7:30pm
Tue: 7:30 am – 7:30 pm
Wed: 7:30 am – 7:30 pm
Thur: 7:30 am – 7:30 pm
Fri: 7:30 am – 5:30 pm
Sat: Closed

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© 2025 Londonderry Animal Hospital.
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Home
Client Info
About Us
Pet Health
Contact Us
Download App
- Vet2Pet for Android
- Vet2Pet for IOS
Online Store

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