Free vet release form

Dec 24, 2019 | Free Dog Walking Resources | 0 comments

TEMPLATE

Copy and paste into a word processor and then print out.

Veterinary release form

 

Owner’s Full Names: ______________________________________________
Address: _______________________________________________
Address: ______________________________________________
Address: ______________________________________________
Address: ______________________________________________
Contact Telephone: ______________________________________________
Mobile: ______________________________________________
Emergency Contact Name _________________________________________
Emergency Contact Telephone ______________________________________

 

Pet No 1. Name: ______________________________________________
Description: ________________________________________________
Age: ______________________________________________
Medical conditions/medication: _______________________________________

 

Pet No 2. Name: ______________________________________________
Description: ________________________________________________
Age: ______________________________________________
Medical conditions/medication: _______________________________________

 

Pet No 3. Name: ______________________________________________
Description: ________________________________________________
Age: ______________________________________________
Medical conditions/medication: _______________________________________

 

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

 

Veterinary Office Name:___________________________________________

Address: _______________________________________________
Address: ______________________________________________
Address: ______________________________________________
Address: ______________________________________________
Contact Telephone: ______________________________________________

 

Alternate Veterinary Office Name: ____________________________________
Address: _______________________________________________
Address: ______________________________________________
Address: ______________________________________________
Address: ______________________________________________
Contact Telephone: ______________________________________________

 

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 accept full responsibility for all fees and charges incurred in the treatment of any of my pets.

The Dog Walker 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 – Full Names: __________________________________
Dog walker – Signature: __________________________________
Dog Owner’s Signature: _______________________________
Date: _________________________________________

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