Veterinary Release Form

VETERINARY RELEASE FORM

Owner's Name

Address

Phone Number

Work Number

Pet  Name

Description

DOB

Medications

Microchip Number

Pet 2 Name

Description

DOB

Medications

Microchip Number

 

If any of the pets named above becomes ill or is injured, I request Dog Walker to take the pets to:

Veterinary Office

Name

Address

Phone Number

Medications

Pet Insurance No

Policy Company

 

TO WHOM IT MAY CONCERN I hereby authorize the attending veterinarian to treat any of my pets as listed above and I the owner accept full responsibility for all fees and charges incurred in the treatment of any of my pets. The Dog Walker/Pet Sitter is authorized to transport my pet(s) to and from the veterinary clinic for treatment or to request “on-site” treatment if deemed necessary. If I cannot be reached in case of an emergency, the walker shall act on my behalf to authorize any treatment excluding euthanasia. I give permission to approve treatment up to £1,000. I will assume full responsibility upon my return for payment and/or reimbursement for veterinary services rendered up to the above stated amount.

Dog walker/Pet Sitter – Full Name                                                    

Dog walker/Pet Sitter – Signature                                                    

 

Pet Owner's Signature                                                    

Date