Information Form

                                                 Basic Service Agreement
406 Canine Club LLC and its owner/single member along with any applicable agents, officers and employees provides quality professional pet care services, including but not be limited to boarding, day care, and additional specified services found at www.406canineclub.com. The Company will use our best efforts and exercise reasonable prudence and ordinary care in the provision of any and all pet care services provided and performed pursuant to this agreement. For the purpose of this Service Agreement, the term “Company” shall be deemed to refer to the 406 Canine Club LLC and its owner/single member along with any applicable agents, officers, employees providing services for the Client(s) as provided herein. The term “Client(s)” refers to the pet owner and/or homeowner, or their designated agents, officers or employees who are engaging and securing the pet care services of the Company. The term “Pet(s)”, (in both singular and plural forms) shall be deemed to mean any animal(s) under the care and supervision of the Company and receiving services pursuant to this agreement. These terms are also expressly incorporated and made applicable to the Company’s separate Veterinary Release, Consent for Treatment and Limited Power of Attorney document and the Client Information Form executed herewith as a part of engaging the services of the Company.  

Therefore, in consideration of the premises set forth herein and in addition to the above basic Service Agreement provision, the Company and Client(s) hereby agree to the following additional terms and conditions related to the pet care services to be provided, which are as follows:

Payment For Services

Standard Billing: 
It is agreed that Client(s) shall to pay and compensate the Company upon demand and billing for the pet care services provided pursuant to this agreement at the conclusion of the service engagement period. The Company shall be paid for the services provided to the Client(s) at the standard daily rates for those services which are publicized on the Company Website which is found at www.406CanineClub.com . The rate of compensation which applies is the Company’s published rate at the time such services are provided. The standard billing rates shall apply to all services provided, except where there is an agreed non-standard hourly rate as specified below. In addition to either paying the Company the standard specified rate or the agreed special hourly rate as provided below for the provision of pet care services by the Company, the Client Agrees to pay and reimburse the Company for any out-of-pocket costs or expenses incurred for any supplies, or reasonable or necessary expenses or services incurred on behalf of the client during the course and scope of performance of this agreement.

Specialized Billing:
In certain engagements to provide pet care services, a specialized hourly billing rate may be applied due to the nature and extent of additional or specialized services requested or desired by the Client. If applicable and indicated in this Specialized Billing provision, it is agreed that the Client shall pay the Company the sum of $__85______per day for the pet care services provided to the Client, which specialized billing is based on the nature and extent of additional or unique services provided. Client initial here to acknowledge consent (_{clientsFull}____). 

Consent and Authorization For Immediate or Emergency Reasonable and Necessary Veterinary Care For Pet(s) And Notification of Owner
In the event that any Pet(s) being cared for or supervised pursuant to this agreement should become ill, sustain some injury, or should an emergency situation arise which in the best judgment and sole discretion of the Company shall require prompt veterinary treatment, intervention or examination, the undersigned Client(s) hereby expressly authorize the Company to act on Client’s behalf and in my Pet(s) best interests to secure, authorize and contract for veterinary treatment in the name of the Client(s). The Client hereby expressly agrees to be responsible for, to pay for and satisfy any bill for professional veterinary services, medicine, diagnostic tests (to include but not be limited to pre-anesthetic laboratory screening) or supplies related to the provision of immediate or emergency veterinary services as provided by any veterinary medical provider. Alternatively, the Client(s) further agree to reimburse and to repay the Company for the full costs incurred or advanced by the Company, if advance payment was required by the veterinary provider, in relation to the provision of essential or emergency veterinary services. 

 The Company agrees to attempt to reasonably contact, notify and inform the Client(s) in the event of an emergency, accident, or other serious health condition requiring immediate or emergency veterinary care and treatment, so that the owner may be involved in treatment related decisions, if possible. However, in the event of any emergency situation requiring immediate treatment or critical life saving measures, in a circumstance where prior actual notice and approval of the Client for advanced medical or surgical treatment/intervention cannot be secured in a timely or immediate manner by the Company or by the applicable Veterinary Hospital/clinic/Veterinarians, the undersigned expressly authorizes the Company and its owner/single member along with any applicable agents, officers and employees of the Company to secure, expressly authorize and to contract for such essential veterinary treatment. The undersigned Client(s) hereby expressly agrees to reimburse, indemnify and to hold harmless the Company for the cost and expense of any such veterinary medical treatment incurred in order to preserve the life, good health and to advance the best interest of the Pet(s) which is/are the subject of the veterinary medical services provided herein. This provision shall be interpreted consistent with and in concert with the Veterinary Release, Consent For Treatment and Limited Power of Attorney document signed in connection with and as a part of this agreement and which document is expressly incorporated herein by reference, and wherein I have agreed to appoint the Company as my Authorized Agent under the Limited Power Of Attorney granted in the referenced collateral document, which is hereby expressly incorporated herein by reference.

Additional Essential Services or Necessary Supplies
In the event that there are any additional reasonable or necessary services or supplies required in the reasonable judgment and sole discretion of the Company to provide for the health or immediate wellbeing of the Pet(s) during the duration of this agreement and during the absence of the owners, the Client hereby agrees to pay for and to satisfy any such bills, accounts, or indebtedness incurred with the provider or supplier in the Client’(s) name. Client(s) alternatively agrees to reimburse the Company for any such reasonable costs and expenses incurred and which may have been paid in advance by the Company on behalf of the Client(s). These essential services and supplies shall include, but not be limited to emergency temporary boarding, transportation, food, medication or other essential pet supplies which are deemed necessary to provide for the health or immediate well-being and overall best interests of the Pet(s). The Company hereby agrees to exercise sound discretion and reasonable judgment and to secure, contract for, or purchase only a minimal or limited quantity of such essential services or supplies when in the Company’s sole best judgment, such services and supplies are essential and immediately required to promote the pet(s) safety, well-being and overall best interest. 

Release/ Waiver of Liability Provision
This Release/Waiver of Liability provision is approved by Client(s) and entered into pursuant to and shall be governed by applicable Montana law, to include but not be limited to provisions found in Title 27, Chapter 7 of the Montana Code Annotated, along with any applicable case law or legal authority decided by the Montana Courts.

As a Client of the Company, I understand and acknowledge that potential harm, injury or death to my Pet(s) could potentially or inadvertently occur while my Pet(s) is/are under the supervision or in the care of the Company in connection with the pet care services provided by the Company pursuant to this Service Agreement. I further acknowledge and understand that Pet(s) can be unpredictable, and can run away and become lost, be injured or killed, and/or that Pet(s) can potentially cause injury, death or damage to third persons. I further acknowledge and understand that Pet(s) can cause damage to the property of third persons or to the Client’s property. Having been made aware of such potentialities, and in consideration of the pet care services provided in connection with this agreement, I agree to release, defend,  remise and to hold harmless the Company and its owner/single member, as well as any applicable agents, officers or employees of the Company from any legal claim, cause of action  or lawsuit, should the Pet(s) being cared for and being supervised become lost, or sustain an injury or death by the own actions of the Pet(s) or the actions of a third party, or should my property or home or any third party’s person, property or home suffer any injury, death or damage caused by the Pet(s) during the course and scope of the performance of pet care services provided pursuant to this Service Agreement. I further understand that in consideration of the premises set forth herein, that I am releasing and waiving any potential claims for damages  against the Company for any injury received by my Pet(s) or for the death of my Pet(s) or any for any dispute or  disagreement relating to  associated veterinary  costs or other expenses incurred by the Client for immediate or necessary emergency treatment secured by the Company, which  expense, damage or and loss may be sustained by the Client or Pet Owner during the course of provision of pet care services pursuant to this agreement. I further understand that I am further releasing and waiving any legal claim for potential reimbursement from the Company of any cost or expense which may incurred by Client(s) as a result of the pet care services provided pursuant to this agreement. It is expressly agreed that this release and waiver provision applies to any and all damages or losses sustained by Client or any third parties, which damages or losses may arise or be occasioned due to an accident, or alleged mistake, casualty or breach of any common law or statutory legal duty of ordinary care on the part of the Company acting by and through the Owner/Member and or any agents, officers or employees of the Company.

Applicable Law
This agreement shall be interpreted and applied under the laws of the State of Montana.

Applicability To Present and Future Pet Care Engagements
This Service Agreement, Release and Waiver of Liability Form shall be applicable to any original and any subsequent engagement for the provision of services provided to Company to Client(s) for any Pet(s), for which services are engaged at any time, as such services are defined herein.

Provision of Information Concerning Pet(s)
The Owner(s) shall provide Company all required information on the Pet Information Forms requested to be completed for the applicable Pet(s) for whom services are requested pursuant to this Service Agreement. It shall be the sole responsibility of the Pet(s) owners to provide accurate and up to date information to the Company, and to update any such new, additional or changed information relating to a Pet for a subsequent engagement for provision of these services.

Severability
Should any provision of this agreement be declared void or unenforceable by a court of law, it is expressly agreed that all remaining provisions in this agreement shall be deemed severable and that the remainder of this Service Agreement shall be deemed to remain fully in force and effect.

Entirety of Agreement
The provisions set forth herein shall constitute the entirety of this Service Agreement, which agreement may not be modified, except by a writing, agreed to and signed by both the Company and the Client.

This agreement entered into this ___ day of _{date}.

By Client(s):

___________________{clientsFull}______________________  ___________________________________

To any applicable Veterinary Hospital/Clinic and Veterinarian(s): 

                  {vetClinic}

                  {preferredVeterinarian}

 

CONSENT TO ADMINISTER TREATMENT

406 Canine Club LLC has been contracted to provide pet care services for my pet(s) and has my permission and express authorization to place them in your care in case of an emergency or other circumstance indicating a need for potential immediate treatment. 406 Canine Club LLC or its member/owner, agents, officers or 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 and your veterinary clinic to treat my pet(s) and to provide any essential emergency veterinary services which are reasonable and necessary to provide for the immediate safety, health and well-being of my Pet(s) or to seek to preserve my pet’s life in the event of a severe accident, injury or emergency. This authorization shall include any Pre-Anesthetic Laboratory Screening which are necessary based on the veterinarian’s professional judgment for the safety and reasonable care of my Pet(s) prior to any surgery, the surgical procedure itself, any diagnostic tests and for any applicable Post Operative Medications. I expressly agree that I will pay upon demand and will be fully responsible for payment of any fees or charges for reasonable and necessary veterinary services and treatment pursuant to this agreement and as provided below. 

My information is as follows:

Pet Owner: ____{clientsFull}____________________________________________

Address: ___{address}_______________________________________________

Phone: _____{phoneNumber}__________________ 

Pet(s) Name(s) and Species: ___________________________{petName}_______________________________

If above named preferred and requested veterinarian is not available or on call when needed, I agree that another vet in his/her veterinary practice or clinic may provide essential and necessary emergency care for my pets. If neither of these veterinarians are available or in the event of a severe health event, accident or emergency, I give permission for and authorize 406 Canine Club LLC or any owner/member, agent, officer or employee to take my pet(s) to the nearest animal hospital or emergency clinic which is expressly authorized to administer treatment. The provision of this agreement shall be fully applicable to such animal hospital or emergency clinic and their employees.

 I understand and hereby agree that 406 Canine Club LLC and their member/owner agents, officers or employees assume no responsibility for the expenses incurred or the potential loss, injury or death of any pet and that the Company and its personnel are hereby further expressly released from all liability related to any and all veterinary treatment secured or performed pursuant to this agreement. I also agree to be responsible for all special services assessed or incurred by 406 Canine Club LLC for emergency transportation, care, or supervision of my Pet and will pay such fees upon demand by the applicable provider. Otherwise, I agree as a Client that I will alternatively reimburse 406 Canine Club, LLC for such fees and costs incurred if they were paid by the Company. 

 Release/Liability Waiver of Veterinary Clinic. I hereby agree to release, remise and agree to hold harmless the designated veterinarian(s) and/or any veterinarians and their veterinary clinics providing emergency care to my Pet(s) pursuant to this agreement, based on the provision of such reasonable and necessary veterinary care administered in good faith and in accordance with the reasonable standard of ordinary care and professional judgment for a licensed veterinarian in the State of Montana. 
Limited Power of Attorney. To the extent deemed necessary to properly secure and authorize necessary emergency care for my Pet on my behalf as a Client of 406 Canine Club LLC and as the Pet Owner or the Authorized Agent for the Pet Owner, I hereby appoint, specify and designate 406 Canine Club, LLC and its member/owner, agents, officers and employees as my duly authorized agent to make any necessary decisions related to the provision of veterinary care for my Pet(s) in my absence. This Limited Power of Attorney is granted to my designated Authorized Agent in order to secure, give consent and properly authorize any and all such needed essential or necessary emergency veterinary care and treatment for my Pet(s) as referenced above in the Consent To Administer Treatment on my behalf pursuant to Montana law. My Authorized Agent is expressly authorized to sign on my behalf any procedure consent forms requested/required by the applicable Hospital/Clinic or veterinarian.

I expressly agree that this Veterinary Release, Authorization and Consent for Treatment and Limited Power of Attorney has no expiration date unless expressly revoked in writing. This document expressly grants permission and authorization for future veterinarian care without the need for an additional authorization each time 406 Canine Club LLC cares for one or more of my pets or veterinary services are needed, unless revoked as provided herein, so long at the Pet(s) are under the care and supervision of 406 Canine Club, LLC in my absence. 

Executed this ____ day of ___{date}________.

 Print Name: __{clientsFull}________________________________

 
Acceptance of Appointment As Authorized Agent Under Limited Power Of Attorney:

On behalf of the Company providing pet care services, the undersigned representative of 406 Canine Club LLC hereby accepts the appointment as the authorized agent for the Client(s) pursuant to the Limited Power of Attorney provision contained above.

406 Canine Club LLC

By: ___Megan Hollinger________________________________

Company Representative For 406 Canine Club, LLC