Emergency Vet Agreement

To Whom it May Concern:

Owner's Name:

Email:

Owner's Contact information in case of emergency (provide all forms of contact)*:

Other contacts (travel companions, etc. – name and contact information):

Dates of travel or expiration date of this form:

Animal’s name:

Type of animal:

Age of animal:

Weight of animal(lbs):

Sex of animal: MaleFemale

Description of animal (color, markings)*:

Relevant medical history*:

Microchip number (if applicable):

Vaccinations (vaccination, date)*:

Medications (name, dose, frequency, route of administration):

Other medication notes:

Authorized agent: Pet Keepers Los Angeles LLC

Relationship to pet owner: Pet service provider

Contact information for authorized agent: Phone: 310-494-6305
Email: service@petkeepersla.com

Other instructions, if applicable:

I authorize emergency veterinary care costs up to $

I do not authorize euthanasia without my direct consent.

In the event of my animal's death, I wish for the following to be done with his/her remains:

I do not authorize the following procedures/ treatments (provide a description of what is to be done in place of this procedure/treatment):

1.

2.

3.

4.

Other

Owner's Name (Printed)*:

Owner's Signature*

Date*:

Emergency Vet Agreement Form