Veterinary Release & Health Form

Veterinary Release Consent AND Dog's Vaccination / Parasite Treatment Record
As part of our licensing requirements, all clients are requested to complete a Veterinary Release Consent Form and Vaccination / Parasite Treatment Log so we ('New Dawn - Cornwall') can act on your behalf if medical treatment is needed for your dog.

In the event of an emergency, we will make every attempt to contact you (the owner), or the secondary owner and / or the emergency contact / guardian. In the event that no contact can be reached, 'New Dawn - Cornwall' will seek appropriate medical care for your dog.
Your Vets Details

Information for use by 'New Dawn - Cornwall'
Name of current vet practice*
Please keep us updated if you ever change veterinary Practice for your dog
Name of preferred vet (if available)
Address of vet practice*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Out of hours emergency number

Area CodePhone Number
Owners Consent to provide veterinary treatment for your dog
In the event that your dog requires veterinary treatment whilst staying at 'New Dawn - Cornwall', where reasonably practicable your dog will be taken to its own veterinary practice for treatment. If this is not possible or is 20+ miles away, your dog will be taken to either:

Edhen Vets - Truro or Newquay branch

Kernyk House, Shortlanesend, Truro, TR4 9DD
Telephone: 01872 228873

Beaver Lodge, Trevelgue Road, Porth, Newquay, TR8 4AT
Telephone: 01637 838233

www.edhenvets.co.uk

Or

Beacon Vet Care - Summercourt or Newquay branch

Chapel Parc, Chapel Town, Summercourt, Newquay TR8 5AH
Telephone: 01872 890100

Church St, St Columb Minor, Newquay, TR7 3ET
Telephone: 01637 695100

www.beaconvetcare.co.uk
I consent for my dog to be taken to the above veterinarian should it require treatment or there is evidence of external parasites on my dog during their stay (i.e. fleas, ticks, lice, etc). I give my consent for my dog to be treated with an appropriate product authorised by the Veterinary Medicines Directorate and licensed for used in the UK. Treatment will be discussed with a veterinarian before administering and if my dog requires preventative treatment, I give my consent that this is given under the direction of a veterinarian.

YesNo

Veterinary Release Form

We advise all clients to provide a copy of this consent, so that it can be added to your dogs veterinary file.
Name of current veterinary practice*
Please keep us updated if you change veterinary Practices for your dog
During my absence, Emma Matthews of 'New Dawn - Cornwall', will be caring for my dog.

In the event of an emergency, I authorise you (veterinarian) to administer medical treatment and I will be responsible for payment to you (veterinarian) upon my return.

I, the below named client, give Emma Matthews of 'New Dawn - Cornwall', permission to transport my pet(s) to the above veterinarian and authorise treatment in the event of an emergency or sickness.

If this veterinarian is not available or located more than 20 miles away, I authorise Emma Matthews of 'New Dawn - Cornwall', to transport my pet to a veterinarian of their choice and authorise treatment.

If emergency care is needed after regular office hours, my pet may be taken to the nearest Veterinarian Emergency Clinic/Hospital.

I give permission to Emma Matthews of 'New Dawn - Cornwall', to approve treatment up to:
(input maximum £ amount or “no limit”)*
I agree to be responsible for all charges upon my return including, but not limited to, vet fees, extra visit fees and transportation fees.

I agree to authorise a veterinarian to euthanize my pet in extreme circumstances after all reasonable attempts have been made to reach me or my emergency contact.
In the event of my pet’s death, I would like the pet:*

CrematedKept at vetOther
If other please detail your requirements:
I agree that Emma Matthews of New Dawn - Cornwall, is released from all liability related to transportation to and from veterinarian and treatment for sickness or emergency. This release will remain valid for all current and future visits unless a new release is signed.
Signature of owner*

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Date*

MonthDayYear
Date
Confirm Name of owner registered with vets*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Postal Code
Phone Number*

Area CodePhone Number
Email*
example@example.com

Pet Information & Medical History
Pet's name*
Date of birth (if known)

MonthDayYear
Date
Sex*
Breed*
Microchip number
Spayed or neutered*

YesNo
My dog is insured*

YesNo
Known medical conditions:

Parasite & Vaccination Log
For further information and guidance on parasites and vaccinations for your dog, visit out website for full details: www.newdawn-cornwall.co.uk/safety

We support all treatments for parasites including natural remedies to treat worms, fleas and ticks - please list what you use below.
Date of last worming treatment?*

DayMonthYear
Date
Name of parasite product*
Date of last Parasite (flea / tick) treatment *

DayMonthYear
Date
Name of parasite product*
Vaccination Log Book / Evidence of vaccinations (email from vet)*

Please provide an image of your dogs vaccination history / log book / medical history from vets
Cancelof
Date of last Canine Parvovirus, Distemper & Adenovirus / Infectious Hepatitis vaccination (required every 3 years unless Titre tested)*

DayMonthYear
Provide last date vaccination given
Date of last Leptospirosis (required yearly)*

DayMonthYear
Provide last date vaccination give
Date of last Kennel Cough (Bordetella Bronchiseptica/Canine Parainfluenza Virus)

DayMonthYear
This vaccination is not a requirement to board with us but we do advise having these booster vaccinations yearly.Please note that we are unable to board any dog that has had the Kennel Cough vaccination within 2 weeks prior to the boarding date due to the vaccination being a live ingredient.
Date of Antibody Titre Test (optional)

DayMonthYear
Date
A titre test may reduce the frequency of some of the core vaccinations that your dog requires.

At New Dawn - Cornwall, we are happy to accept this certificate from your vet to evidence they have sufficient antibody levels in their blood.

Unsure of what a titre test is? Visit our web page for more information: www.newdawn-cornwall.co.uk/safety
Upload Titre Test confirmation from vet

Please provide a copy of your Titre Test Certifcate if your dog has had one done instead of having their DHPP vaccination.
Cancelof
I confirm that the above record is true and correct to the best of my knowledge.
Signature*

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Name*

First NameLast Name
Date*

DayMonthYear
Date
Should be Empty:

Veterinary Release Consent AND Dog's Vaccination / Parasite Treatment Record

Your Vets Details

Owners Consent to provide veterinary treatment for your dog

Veterinary Release Form

Pet Information & Medical History

Parasite & Vaccination Log