Emergency Contact Information Form - County Animal Hospital

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COUNTY ANIMAL HOSPITAL
EMERGENCY CONTACT INFORMATION
Complete form online and Print or Print and complete offline. Bring form to CAH on day of
boarding your pet.
Date: ______________
Owner’s Name: __________________________________________
Pet’s Name(s):______________________________________________________________________
Contact Phone Numbers _____________________________
__________________________
Emergency Contact Name:__________________________________________________
Alternate Tele. No. _____________________________
________________________________
If an unforeseen event occurs and emergency treatment is needed for your pet please indicate to
what level you would like us to proceed if we cannot reach you immediately:
Do not administer emergency care without talking to me or ____________________________ first.
Administer only what is immediately necessary to save the life, but do not perform further diagnostic
work ups until you have spoken with me or ______________________________________.
Please perform any life saving needs required in the event of an emergency if I cannot be reached
immediately.
Do Not Resuscitate
NOTE: We will continue to attempt to contact you as soon as possible regarding your pet’s
health in the case of an emergency. (Please make sure we have current contact and emergency
contact information from you).
I want to fill out this form each time I leave my pet for boarding/hospitalization, OR
The information contained above remains in effect for one year from the date below.
I accept full financial responsibility and agree to settle the balance as services are rendered, or
upon discharge. I agree to pay any costs and charges necessary for the collection of any amount
not paid when due.
Signed: __________________________________________________ Date: _____________________
(All information will be kept in CAH records for 1 year.)
Submit
Reset Form
Print
Rev. 02/05/2017

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