Veterinary Instructions and Release Form for In My Home Care
   
                  Dog    Cat      Bird     Horse
   
   
   
   
Pet's Name
Description
Age
Medical Conditions/Medications
   
Pet's Name
Description
Age
Medical Conditions/Medications
 
If any of the pets named above becomes ill or is injured, I request that Beverly Hardy take the pets to:
   
Veterinary Office Name
Address
 
Phone Number
   

Alternate Veterinary Office Name
Address
 

 

I give permission to Beverly Hardy to approve treatment up to $

 

I will assume full responsibility upon my return for payment and/or reimbursement for veterinary services rendered up to the above stated amount.

If neither of the veterinary offices named above is available, I authorize Beverly Hardy to take my pets to another veterinary office for treatment. I understand that Beverly Hardy cannot be held responsible for the results of the veterinary treatment or the loss of my pet.

This agreement is valid starting on the date below whenever Beverly Hardy cares for my pets.
   
Owner's Signature*
Date
Owner's Name
Owner's Email
Owner's Address
Owner's Cell Number*
Alternate Contact Name/Number
Alternate Contact Name/Number
 
*Required fields