Pet Nanny of Topeka
Dog Walking & Pet Sitting Services
(785)235-3735 petnannytopeka@sbcglobal.net
____VETERINARY MEDICAL CARE RELEASE FORM___
In the event of a medical emergency, where Pet Nanny of Topeka cannot contact you to authorize care immediately and directly, Pet Nanny of Topeka will use this form to obtain care. A copy of this form will be faxed to your vet to be placed in your file to expedite any emergency care needed. ***Please print clearly tin blue of black ink***
Primary Veterinarian’s Information
Name of Vet Hospital or Clinic:____________________________________________________________
Address:_______________________________________________________________________________
Name of preferred Doctor:_________________________________________________________________
I, ___________________________ (pet owner), hereby give Pet Nanny of Topeka my express permission to transport any of my pets for care to the abovementioned veterinarian (or to closest open facility if the Primary Vet office is not available). I give permission for the hospital/clinic/doctor to administer any care or medications necessary.
I understand that Pet Nanny of Topeka will try to contact me as soon as possible in the event of a medical emergency. If Pet Nanny of Topeka cannot contact me, I give permission to Pet Nanny of Topeka to approve treatment up to $__________ per pet (most common values are $200, $1000 or unlimited).
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. Such payments will be made within 14 days of the initial incident. I also agree to be responsible for all Special Service fees assessed by Pet Nanny of Topeka for emergency transportation, care, supervision, or hiring of emergency caregivers, and will pay such fees within 14 days of each incident.
List of Pets:
Name/Description or Breed:_______________________________________________________________
Name/Description or Breed:_______________________________________________________________
Name/Description or Breed:_______________________________________________________________
Name/Description or Breed:_______________________________________________________________
Name/Description or Breed:_______________________________________________________________
If anything changes from the information listed above, I will inform Pet Nanny of Topeka before the next service is scheduled to begin.
This agreement is valid from the date below and grants permission for future veterinary care without the need for additional authorization each time Pet Nanny of Topeka cares for one or more of my pets. In signing this contract, I agree that I have the authority to make health, medical and financial decisions regarding the animals that will be scheduled to receive service.
X_________________________________ X___________________________ ____/____/20____
Signed Name Printed Name