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					Pet Owner’s Name: _________________________________                 Pet’s Name: ____________________



                                             Medication Waiver


Pet Info:
Age: ___________        Male / Female       Breed: ______________________________

Colors/Markings: __________________________            Spayed / Neutered


Health Record (Must fill out new form after each Vet visit or when new medications are
required)

Date of Last Check-up: _____________ Vaccinations: ________________________________________

Known illnesses:

_____________________________________________________________________________________

_____________________________________________________________________________________

Veterinarian Information:
Veterinarian Name:

______________________________________________________________________

Complete Address:

______________________________________________________________________

Phone Number: _________________________________________________________

Permission to use our veterinarian in the event above veterinarian is not available:   □ Yes □ No

Medication Info:         Number of medications needed during service contract: ________________




                                                 Page 1 of 4
Pet Owner’s Name: _________________________________                Pet’s Name: ____________________


Name of Medicine #1:_______________________________ Amount Given: ______________________

(For additional medications, please fill out addition medication information on the next sheet

Time to Administer: _______________ Give meds _________ times a day for ______ days

Reason for Medication:

_____________________________________________________________________________________

Known side effects:

_____________________________________________________________________________________

Instructions for administration:

_____________________________________________________________________________________

Has pet been on this medication before:   □ Yes □ No
Any known problems with administering:      □ Yes □ No
Please Describe:

____________________________________________________________________________________

Furry Family Pet Sitting, LLC and staff agree to administer medication to above pet per the instructions
listed above. Furry Family Pet Sitting, LLC is not responsible for any reaction pet has to the medication.
If pet needs emergency vet care, owner agrees to be responsible for all cost incurred including
transportation and vet fees. Owner agrees to hold Furry Family Pet Sitting, LLC harmless of any claims
unless gross negligence has been proven. This agreement will remain valid until a new agreement has
been filled out.

I, ________________________________________, have entered the above information as
truthfully and accurately as possible and give Furry Family Pet Sitting, LLC permission to
administer listed medications.

       
       
      
       
       
      


___________________________________________________                        _____________
               Client Signature 

  
     
     
                         
      Date




                                                Page 2 of 4
Pet Owner’s Name: _________________________________         Pet’s Name: ____________________


2. Additional Medication Information:

Name of Medicine #2:_______________________________ Amount Given: ______________________

Time to Administer: _______________ Give meds _________ times a day for ______ days

Reason for Medication: _________________________________________________________________

Known side effects: ____________________________________________________________________

Instructions for administration: ___________________________________________________________

Has pet been on this medication before:   □ Yes □ No
Any known problems with administering:     □ Yes □ No
Please Describe:

____________________________________________________________________________________

3. Additional Medication Information:
Name of Medicine #3: ________________________________ Amount Given: ____________________

Time to Administer: _______________ Give meds _________ times a day for ______ days

Reason for Medication: _________________________________________________________________

Known side effects: ____________________________________________________________________

Instructions for administration: ___________________________________________________________

Has pet been on this medication before:   □ Yes □ No
Any known problems with administering:     □ Yes □ No
Please Describe:

____________________________________________________________________________________




                                              Page 3 of 4
Pet Owner’s Name: _________________________________         Pet’s Name: ____________________


4. Additional Medication Information:
Name of Medicine #4: _______________________________ Amount Given: _____________________

Time to Administer: _______________ Give meds _________ times a day for ______ days

Reason for Medication: _________________________________________________________________

Known side effects: ____________________________________________________________________

Instructions for administration: ___________________________________________________________

Has pet been on this medication before:   □ Yes □ No
Any known problems with administering:     □ Yes □ No
Please Describe:

____________________________________________________________________________________


5. Additional Medication Information:
Name of Medicine #5: _______________________________ Amount Given: _____________________

Time to Administer: _______________ Give meds _________ times a day for ______ days

Reason for Medication: _________________________________________________________________

Known side effects: ____________________________________________________________________

Instructions for administration: ___________________________________________________________

Has pet been on this medication before:   □ Yes □ No
Any known problems with administering:     □ Yes □ No
Please Describe:

____________________________________________________________________________________




                                              Page 4 of 4

				
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posted:9/18/2011
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