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Veterinarian Release

 

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VETERINARIAN RELEASE
Date:__________Client’s Name:_________________________Address:______________________________

Email Address: ____________________________Telephone _______________________________________

Emergency Person’s Name(s) and Telephone(s):__________________________________________________

 

**Please fill out one form for each cat so that we may provide the best possible
care for your pet.  Thank you

Pet’s Name: ________________________(Please circle)   Dog      Cat      Bird      Fish      Other

Birth Date: _____________   Weight ________Known medical conditions:

Pet’s Name: ________________________(Please circle)   Dog      Cat      Bird      Fish      Other

Birth Date: _____________   Weight ________Known medical conditions:

Pet’s Name: ________________________(Please circle)   Dog      Cat      Bird      Fish      Other

Birth Date: _____________   Weight ________Known medical conditions:

Pet’s Name: ________________________(Please circle)   Dog      Cat      Bird      Fish      Other

Birth Date: _____________   Weight ________Known medical conditions:

Veterinarian Information:

Name: _______________________________________________

Telephone:________________________________________________________________

Address: ___________________________________________________

Email: _____________________________________________________


During my absence, Woof-Purr LLC will be caring for my pet(s). In the event of an emergency,

I authorize you (veterinarian) to administer medical treatment and will be responsible for payment to you (veterinarian) upon my return.

I, __________________________________, give Woof-Purr LLC permission to transport my pet(s) to the above veterinarian or nearest emergency hospital and authorize treatment in the event of an emergency or sickness. Regular veterinarian must have credit card information on file.

If this veterinarian is not available, I authorize Woof-Purr LLC to transport my pet(s) to a veterinarian of choice and authorize treatment.

If emergency care is needed after regular office hours, my pet(s) may be taken to the nearest Veterinarian Emergency Clinic/Hospital.

I give permission to Woof-Purr LLC to approve treatment up to $_____________________ (input maximum dollar amount or “no limit”). (This is very important that the maximum dollar amount is entered).

I agree to be responsible for all charges upon my return including, but not limited to, vet fees, extra visit fees and transportation fees.

I agree to authorize veterinarian to euthanize my pet in extreme circumstances after all reasonable attempts have been made to reach me or my emergency contact.

In the event of my pet’s death, I would like the pet cremated / kept at vet / other: _________________.

I agree that Woof-Purr LLC is released from all liability related to transportation to and from veterinarian and treatment for sickness or emergency.

This release will remain valid for all current and future visits unless a new release is signed.

 

__________________________    _________________

Client’s Signature                              Date


 

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Posted in forms by WoofPurr.la on October 21st, 2014 at 1:26 am.

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