Veterinary Release Form

Veterinary Release Form
Owner Contact Information
Clients Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACT
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Pet Information Details
Pet(1) Name*
Pet Age*
Breed*
Color/Markings*
Does your dog require being muzzled at the vet?*

YesNoI don't know
Medical Conditions
Pet(2) Name
Pet Age
Breed
Color/Markings
Medical Conditions
AUTHORIZATION FOR VETERINARY TREATMENT

I, the undersigned, am the legal owner or authorized agent of the above-named pet. I hereby authorize Patriot K Nine LLC and its staff to provide medical treatment, examinations, procedures, and any necessary medications or surgeries as deemed appropriate for my pet's health and well-being. I understand that every effort will be made to contact me in case of emergencies or significant medical decisions.

I authorize Patriot K Nine LLC to receive a copy of my dogs veterinary vaccine and medical records and to retain that copy at their facility.

Patriot K Nine LLC will take my pet to the veterinarian I have identified in this document and provided a record for. In the event my veterinarian is unable to see my pet, they will take my pet to Highland Animal Hospital (Fayetteville NC) during regular business hours or Points East Emergency Animal Hospital (Fayetteville NC) after regular business hours.
Veterinarian Clinic*
Phone Number
Please enter a valid phone number.
City/State*
CONSENT FOR MEDICAL TREATMENT (Mark All That Apply) I understand that medical procedures, treatments, and medications are not without risk. I authroize the veterinary team to perform the following procedures, if neccessary for the benefit of my pet's health with Patriot K Nine LLC as my representative:*

Physical ExaminationVaccinationsAdminstration of MedicationsDiagnostic Tests (e.g: blood work, x-rays)SurgeryDental ProceduresHospitalization and Monitoring
ESTIMATED COSTS AND PAYMENT

I understand that I am responsible for the costs of all medical services provided to my pet if the diagnosis results from a condition that occurred before they arrived at Patriot K Nine LLC. This includes any conditions or behaviors resulting in injury or illness while in the care of Patriot K Nine LLC, that were not disclosed during the consultation or in their contract, which was signed before my pet entered training.

I authorize Patriot K Nine LLC to have a copy of my veterinary bill for their records, documentation, and insurance claims if necessary.

I agree to make payment in full at the time of services rendered and understand that additional charges may apply based on unforeseen circumstances or complications during treatment.

EMERGENCY CARE AUTHORIZATION

In the event I cannot be reached, I authorize the veterinary team to provide emergency medical treatment for my pet as they see fit. I understand that every effort will be made to contact me or my emergency contact before any major decisions are made regarding my pets care.

RELEASE OF LIABILITY

I acknowledge that there are inherent risks associated with medical treatments and procedures. I release Patriot K Nine LLC, designated veterinarians, staff members, and associated personnel from any liability arising from treatment decisions made for my pet.

By signing this form, I acknowledge that I have read and understood the contents and implications of the Veterinary Treatment Release Form. I authorize and content to the medical treatment outlined above for my pet.

STATUTE OF LIMITATION

This document is valid for ONE (1) Calendar year from the date signed; any updates will void previous copies on file and will need to be renewed annually.
Date

MonthDayYear
Date
Pet Owner Name*

First NameLast Name
Pet Owner Signature*

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Veterinary Release Form

Owner Contact Information

EMERGENCY CONTACT

Pet Information Details