VIEWS: 459 PAGES: 2 CATEGORY: Legal Forms POSTED ON: 5/19/2010
Do you provide pet sitting services? Have your clients fill out this Emergency Veterinary Care Authorization & Release form for each of the pets that they leave in your care.
The authorization form is a continuing authorization, giving the authority:
- to the pet sitter to contact the specified veterinarian in the event that a pet requires medical attention, or to obtain alternate veterinary care if the client's veterinarian is not available;
- to the veterinarian, to diagnose and treat the animal as necessary, with an optional clause to set a limit on the cost of such treatment. The client also acknowledges sole responsibility for payment of the costs and expenses, and certifies that the pet is up to date on its vaccinations. The client also releases the pet sitter from liability.
This Emergency Veterinary Care Authorization & Release template is provided in MS Word format. Pay for the form once, and it's yours to use as often as you require.
EMERGENCY VETERINARY CARE AUTHORIZATION & RELEASE In the event any pet of mine becomes ill or injured while in the care of [NAME OF PET SITTING SERVICE] (the “Service”), I hereby authorize the Service to transport the pet to the following veterinarian to diagnose and treat its condition: HOSPITAL/CLINIC: DOCTOR NAME: ADDRESS: PHONE NUMBER(S) EMERGENCY CONTACT: In the event the above veterinarian is not available, I authorize the Service at its discretion to obtain veterinary care from another veterinarian in the same clinic, or a different veterinarian / veterinary clinic, or an emergency care clinic, as it deems appropriate. I understand that all efforts will be made to contact me regarding my pet’s condition, diagnoses and suggested treatment. However, if it is not possible to contact me, I authorize the veterinarian or emergency care clinic to diagnose and treat my pet at his/her discretion, [if applicable: to a maximum treatment limit of $_________ per pet]. I further authorize my pet’s veterinarian to provide access to medical records for my pet(s) to any additional veterinarian(s) or clinics who are involved in providing treatment or care to my pet(s). I understand that I am solely responsible for the payment of and/or reimbursement to the Service for any and all veterinary services rendered, including but not limited to diagnosis, treatment, medical supplies, kenneling, and special diet. I agree to pay all such costs within ______ days of receiving notice of same. I further agree to pay the Service’s charges for emergency transportation, supervision and emergency care giving within ___ days of being invoiced for the same. In the event that the veterinarian requires immediate payment, it
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