Veterinarian Release
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~~~~ Veterinary Release ~~~~
Hospital and Vet’s Name:____________________
Address:_____________________________
Phone: ______________________________
Fax: ______________________________
To the Hospital:
During my absence, a representative of Lucky Puppy, LLC will be caring for my pet(s) and has my permission to transport them to your office for treatment. I authorize you to treat my pet(s) and will be responsible for payment to you upon my return. Please file this form with my records.
Pet Owner:_________________________
Address:____________________________
Phone: ______________________________
Pet(s) Names:_______________________
I, ____________________________ (client) hereby give Lucky Puppy, LLC my express permission to transport any of my pets for care to the above-mentioned veterinarian.
I give permission to Lucky Puppy, LLC to approve treatment up to $____________. I will assume full responsibility upon my return for payment of veterinary services rendered. ( _____ initial)
If above named veterinarian is not available, another vet in his/her veterinary group is / is not acceptable. If emergency care is needed after regular veterinary office hours, my pet(s) may / may not be taken to the nearest Emergency Veterinary Clinic. ( _____ initial)
I understand that Lucky Puppy, LLC assumes no responsibility for the loss of any pet and is released from all liability related to transportation, treatment and expense.
I do / do not agree to authorize said veterinarian to euthanize my pet in extreme circumstances under his/her advisement after all reasonable attempts have been made to reach me. ( _____ initial)
This consent for treatment has no expiration date unless otherwise noted. A photocopy/facsimile of the signed consent shall have the same force and effect as the Client/Pet Owner’s original signature.
*You may also choose to leave credit card on file with Veterinarian.
Client__________________Date___________________Lucky Puppy, LLC____________ Date_____________
You must print, sign and date this form before any service can be rendered. Thank You.