Pet Information

VETERINARY RELEASE FORM

Owner's Name ................................................................................................................................................................

Address ................................................................................................................................................................

Phone Number ................................................................................................................................................................

Work Number ................................................................................................................................................................

Pet 1 Name ................................................................................................................................................................

Description ................................................................................................................................................................

DOB ................................................................................................................................................................

Medications ................................................................................................................................................................

Microchip Number ................................................................................................................................................................

If the pet named above becomes ill or is injured, I request _____________________takes the pet to:

Veterinary Office Name ................................................................................................................................................................

Address ................................................................................................................................................................

Phone Number ................................................................................................................................................................

Pet Insurance No ................................................................................................................................................................

Policy Company ................................................................................................................................................................

TO WHOM IT MAY CONCERN

I hereby authorise 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 authorised 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 authorise 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 Name ................................................................................................................................................................

Signature ................................................................................................................................................................

Pet Owner's Signature ................................................................................................................................................................

Date ................................................................................................................................................................