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Custom Care and Loving Service                                                                                              (619) 583-0730

VETERINARY INSTRUCTION AND RELEASE FORM

Pet’s Name_________________________Age________Description_______________________

Pet’s Name_________________________Age________Description_______________________

Pet’s Name_________________________Age________Description_______________________

Pet’s Name_________________________Age________Description_______________________

If any of the above named pets should become ill or injured, I request that Vicki’s Pampered Pet Care

take the pets to:

Hospital___________________________________________Vet_________________________

Address_________________________________________________Phone_________________

Alternate Vet______________________________________________Phone________________

Address_______________________________________________________________________

Medical Problems_______________________________________________________________

_____________________________________________________________________________

Medication____________________________________________________________________

I give permission to Vicki’s Pampered Pet Care to approve treatment up to $_____________. 

I will assume full responsibility upon my return for payment and/or reimbursement for veterinary

services rendered.

If the above named veterinarians are not available, another vet is acceptable.

I understand that Vicki’s Pampered Pet Care assumes no responsibility for the actions and decisions

of the veterinary staff or the loss of my pet.  If my pet should die while under the care of Vicki’s Pampered

Pet Care I request that the following arrangements be made:  ___________

_____________________________________________________________________________

This agreement is valid from the date below and grants permission for future veterinary care without the

 need for additional authorizations each time Vicki’s Pampered Pet Care cares for my pet(s).

Comments/Instructions__________________________________________________________

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Owner’s Name (please print)______________________________________________________

Owner’s Signature_____________________________________Date______________________