2008-2009 2008-2009 Veterinary Care Release Form
Animal’s Name(s) _______________________________________________________________________
Birth Date(s) ___________________________ Regular Veterinarian’s Phone # ____________________
Regular Veterinarian’s Clinic ___________________________ __________________________________
Known Medical Conditions
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
During my absence, “Raven One Premier Pet Services” will be caring for my pet(s). In the event of an emergency, I, _____________________________________, authorize you (veterinarian) to administer medical treatment and I will be responsible for payment to you (veterinarian) upon my return.
I give “Raven One Premier Pet Services” permission to transport my pet(s) to the above veterinarian and authorize treatment in the event of an emergency or illness.
If this veterinarian is not available, I authorize “Raven One Premier Pet Services” to transport my pet(s) to a veterinarian of their 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 “Raven One Premier Pet Services” to approve treatment up to $___________ (input maximum dollar amount or “no limit”). 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.
I agree that “Raven One Premier Pet Services” is released from all liability related to transportation to and from veterinarian and treatment for illness or emergency.
Client Signature: _____________________________________________ Date: ________________
 |
 |
 |