Veterinary Instructions And Release Form!

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300 Millburn Ave #185!
Millburn, NJ 07041
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(862) 520-8245
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VETERINARY INSTRUCTIONS AND RELEASE FORM!
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Silver Hound Dog Walking, LLC has been contracted to pet sit for my pet(s) in my absence and has my
permission to place them in your care in case of an emergency. Silver Hound Dog Walking, LLC will attempt to
contact me as soon as medical care is deemed necessary. However, in the event I cannot be reached
immediately, I ask Silver Hound Dog Walking, LLC to inform the attending clinic or veterinarian of my requested
total diagnosis and treatment limit of $ __________ per pet. I trust that efforts will be made to contact me
regarding any treatments, illnesses, injuries or potential problems as soon as the condition has been deemed not
life threatening or as sons as I become available. I understand that Silver Hound Dog Walking, LLC cannot be
held responsible for the costs or results of the veterinary treatment or the loss of my pet and is released from all
liability related to transportation, treatment and expense. Further I will assume full responsibility for the payment
and/ or reimbursement for any and all veterinary services rendered, including, but not limited to: diagnosis,
treatment, grooming, medical supplies and boarding.!
Please file this form with my records.!
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Pet’s Name: _______________________________________ Species: ________________________________!
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Color/Markings: ______________________________ Age: ___________ !
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Medical conditions/medication: _________________________________________________________________!
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Pet’s Name: _______________________________________ Species: ________________________________!
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Color/Markings: ______________________________ Age: ___________ !
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Medical conditions/medication: _________________________________________________________________!
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If any of the pets named above become ill, injured, or appears to be at significant risk of a medical problem, I
request that Silver Hound Dog Walking, LLC take the pet(s) in order to receive treatment to: !
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Veterinary Office Name: _____________________________________________
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Address:
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_________________________________________________ Phone: _______________________!
or !
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Veterinary Office Name: _____________________________________________
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Address:
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_________________________________________________ Phone: _______________________!
If neither of the veterinary offices named above is available, I authorize Silver Hound Dog Walking, LLC to take
my pet(s) to another veterinary office for treatment.!
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This agreement is valid beginning on the date below and anytime thereafter when Silver Hound Dog Walking,
LLC cares for my pets. !
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____________________________________
_______________________________
__________________!
Owner’s Signature
Owner’s Name (please print)
Date!
     
I

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