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Medication Waiver

 

MEDICATION WAIVER

Date:_________________________________

Email Address: __________________________
Pet’s Name:____________________________
Telephone:_____________________________
Emergency Person’s Name and Telephone:___________________________________________

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*Please fill out one form for each pet so that we may provide the best possible care for your pet!

Owner’s Name: _____________________________________________________________
Pet’s Name: ______________________________________ DOB: ___________ Male / Female
Type of Pet: ___________________________ Breed: ___________________ Spayed / Neutered

Health Record (Must fill out new form after each Vet Visit or when new medications are required)

Date: of Last Check-up: ________________________
Vaccinations:_____________________________________
Known illnesses: _______________________________________________________________________

Veterinarian Information:

Veterinarian Name: _____________________________________________________________________
Complete.Address:___________________________________________________________
Phone Number: _____________________________________________________________
Permission to use our veterinarian in the event about veterinarian is not available: □ Yes □ No

Medication Information:
Number of medications needed during service contract :_________________
Name of Medication (only enter one medication here): ___________________
Amount Given: _______
Times to Administer Medication: _________________________
Dosage Each Time ____________________
Reason for Medication: ____________________________________________________________
Known side effects: _______________________________________________________________
Instructions for administration: _______________________________________________________
Has pet been on this medication before: Yes No
Any known problems with administering: Yes No
Please Describe: __________________________________________________________________________

Is your dog allergic to bee stings? YES NO Don’t Know
If yes, what steps would you like Woof-Purr LLC to take if your dog is stung by a bee?
_________________________________________________________________________________________

(For additional medications print an extra page)

Woof-Purr LLC and staff agree to administer medication to above pet per the instructions listed above. Woof-Purr LLC shall not be responsible if pet refuses medication. Woof-Purr LLC shall not be responsible for any reaction pet has to medication. If pet needs emergency vet care, owner agrees to be responsible for all cost incurred including transportation and vet fees. Owner agrees to hold Woof-Purr LLC harmless of any claims unless gross negligence has been proven. This Agreement will remain valid until a new agreement has been filled out.

I, ________________________________________, have entered the above information as truthfully and accurately as possible.

_________________________________________________
Client Signature

_________________
Date

Additional Medication Information:

Medication Information:

Name of Medication (only enter one medication here): ___________________
Amount Given: _______
Times to Administer Medication: _________________________
Dosage Each Time ____________________
Reason for Medication: ____________________________________________________________
Known side effects: _______________________________________________________________
Instructions for administration: _______________________________________________________
Has pet been on this medication before: Yes No
Any known problems with administering: Yes No
Please Describe: __________________________________________________________________________

Is your dog allergic to bee stings? YES NO Don’t Know
If yes, what steps would you like Woof-Purr LLC to take if your dog is stung by a bee?
_________________________________________________________________________________________


Name of Medication (only enter one medication here): ___________________
Amount Given: _______
Times to Administer Medication: _________________________
Dosage Each Time ____________________
Reason for Medication: ____________________________________________________________
Known side effects: _______________________________________________________________
Instructions for administration: _______________________________________________________
Has pet been on this medication before: Yes No
Any known problems with administering: Yes No
Please Describe: __________________________________________________________________________

Is your dog allergic to bee stings? YES NO Don’t Know
If yes, what steps would you like Woof-Purr LLC to take if your dog is stung by a bee?
_________________________________________________________________________________________

Number of medications needed during service contract :_________________
Name of Medication (only enter one medication here): ___________________
Amount Given: _______
Times to Administer Medication: _________________________
Dosage Each Time ____________________
Reason for Medication: ____________________________________________________________
Known side effects: _______________________________________________________________
Instructions for administration: _______________________________________________________
Has pet been on this medication before: Yes No
Any known problems with administering: Yes No
Please Describe: __________________________________________________________________________

Is your dog allergic to bee stings? YES NO Don’t Know
If yes, what steps would you like Woof-Purr LLC to take if your dog is stung by a bee?
_________________________________________________________________________________________

 

 

 

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Posted in forms by Colleen Jones on October 21st, 2014 at 2:49 am.

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