VETERINARY RELEASE FORM

VETERINARY RELEASE FORM

NY Fur Nanny
Owners Name

First NameLast Name
Pet’s Info

NameSpecies
VETERINARIAN
Hospital Name
Primary Doctor Name

First NameLast Name
Hospital Phone Number
Please enter a valid phone number.
Hospital Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
***THE CLOSEST EMERGENCY HOSPITAL WILL BE USED IF MY VETERINARIAN IS UNAVAILABLE OR UNABLE TO TREAT MY PET(S)***
To The Hospital:

NY Fur Nanny has been contracted to care for my pet(s) and has my permission to place them in your care in case of an emergency. Stephanie or one of her employees will attempt to contact me as soon as medical care is deemed necessary. However, in the event I cannot be reached immediately, I authorize you to treat my pet(s) and will be responsible for payment of any fees as stated below.
I give permission for NY Fur Nanny to approve treatment costs up to:
Please put dollar amount.
Initials*
I understand that NY Fur Nanny assumes no responsibility for the loss of any pet and is released from all liability related to treatment. I also agree to be responsible for all special services assessed by NY Fur Nanny for emergency transportation, care, or supervision and will pay such fees when due.
Initials*
This consent for treatment has no expiration date and grants permission for future veterinary care without the need for additional authorization each time NY Fur Nanny cares for one or more of my pets.
My pet(s) has/have the following health issues:
Date*

MonthDayYear
Signature*

Clear
Should be Empty: