Veterinarian Release Form - Northbrook Pet Nannies printable pdf download

VETERINARIAN RELEASE FORM

This form will be retained on file and will be used to authorize veterinary treatment in the event that your pet(s) require treatment during

the time Northbrook Pet Nannies Inc. (“NPN”) is providing Services and is unable to contact you despite reasonable efforts to do so.

Should you change veterinarians please notify NPN prior to the provision of Service(s).

Name:_______________________________________________________________________________________

Address: _____________________________________________________________________________________

City: __________________________________________________ ZIP: __________________________________

Home phone: _________________________ Work phone: ____________________________________________

Cell: ________________________________ Email: __________________________________________________

Name of Pet(s): __________________________________________________________________________________

To whom it may concern: Northbrook Pet Nannies Inc. will be walking my pet(s) and/or caring for my pet(s) during my absence and I

authorize veterinary treatment for same. I give Northbrook Pet Nannies Inc. my permission to transport my pets to a veterinarian (or to an

emergency clinic). In the event I cannot be reached, I authorize Northbrook Pet Nannies Inc. to act as an agent on my behalf regarding my

pets’ medical care. I accept full responsibility for charges incurred in the treatment of my pet(s), not to exceed the following amounts:

Dollar Limitation per Animal: $_____________________

Specific limits on care:

NPN reserves the right to utilize the services of any available veterinary clinic in its reasonable discretion. If time permits, we will attempt

to utilize your primary veterinary clinic. If it is not practical to do so, in NPN’s sole discretion, the following information will be helpful if

the clinic we utilize requires documentation from your primary clinic.

Veterinary Clinic/Vet: __________________________________________________________________________

Address: _____________________________________________________________________________________

City: ________________________________________ Zip Code: _______________________________________

Phone: _______________________________Emergency Phone: ________________________________________

I authorize veterinary treatment for my pet(s) during my absence. I understand that NPN assumes no responsibility for the loss of any pet(s)

and is released from all liability related to transportation, treatment and any related expense. I will be responsible for any and all charges

incurred during the treatment of my pets pursuant to the conditions of this authorization and hereby agree to indemnify NPN for any and all

costs and expenses related to the care of my pet(s) provided pursuant to the terms of this Release.

Signature:

_____________________________________________ Date:_______________________________

Print Name: ______________________________________________

Veterinarian Release Form - Northbrook Pet Nannies