Medical Release Form

Medical Release Form

Coastal Animal Referral Emergency
Client Name:

First NameLast Name
How will we be able to reach you while away?
Email
example@example.com
Phone Number
Please enter a valid phone number.
Valid From:

MonthDayYear
Date
Valid To:

MonthDayYear
Date
Pet Information
Pet Name

First NameLast Name
Pertinent Medical Information
Pet's Allergies and Medical Conditions:
Pet's Medications:
Pet Sitter Information
Pet Sitter Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
CPR Directive
The doctors and staff at CARE will make every effort to prevent complications arising from your pet’s illness/injury or procedures performed in our hospital. Unlike humans, the percentage of pets that fully recover after receiving CPR is typically less than 5%.

Please confirm your wishes for your pet in your absence:
Do Not Resuscitate – DNR (no CPR will be performed) This option is always an acceptable choice based upon your beliefs and needs. In the event your pet is suffering, humane euthanasia may be performed.Attempt Resuscitation (CPR will be initiated and all efforts will be made to resuscitate your pet. Costs associated with CPR may be $400-$500 in addition to your estimate).
Financial Responsibility

Please choose ONE option below:
Type a question

In case of an emergency, I authorize all medical treatment be completed regardless of costIn case of an emergency, I authorize only the exam ($155) be completed until CARE can contact me for further authorizationIn case of an emergency, I authorize medical treatment up to this dollar amount prior to contacting me for further authorization
What is the dollar amount you authorize prior to contacting you?
How will we be processing payment?

My pet sitter will pay the invoice at time of servicePlease call me to process financial transactions over the phone
Do you have Pet Insurance?

Insurance CompanyPolicy Number
Final Authorization
Should your pet require anything significant such as a medical procedure under anesthesia or euthanasia, does your pet sitter have permission to authorize such treatments or procedures?*

YesNo, my pet sitter is not allowed to make this decision, please contact me
If we are unable to contact you, please let us know how you would like us to proceed:*
I consent to receive text messages from CARE. Message rates vary. Not all carriers are covered. Standard message and data rates apply. You may update your preference, and cancel your consent, by notifying us at any time or by replying STOP to any text message you receive from us.

I acknowledge and agree to the above statement
Client Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Medical Release Form

Pet Information

Pertinent Medical Information

Pet Sitter Information

CPR Directive

Financial Responsibility

Final Authorization