Owner's Name:____________________________________________________________ Home Address:____________________________________________________________ Telephone Number:________________________________________________________ Pet’s Name:______________________________________________________________ Description:_______________________________________________Age:___________ Medical conditions/medication:____________________________________________ _________________________________________________________________________ If the above named pet(s) becomes ill or is injured, I request that Joanne Tamburro take the pet to: Veterinary Office Name:______________________________________________________ Address: ___________________________________________________________________ Phone Number: _____________________________________________________________ TO THE VETERINARIAN/CLINIC/HOSPITAL: During my absence, Joanne Tamburro will be caring for my pet(s) and has my permission to transport them to your facility for treatment. I authorize you to treat my pet(s) and will be responsible for payment to you upon my return. I give permission to Joanne Tamburro I will assume full responsibility upon my return for payment and/or reimbursement for veterinary services rendered up to the above stated amount. If the veterinary office named above is unavailable, or in the case of an emergency,
if the location is too far, I authorize Joanne Tamburro to take my pet/s
to another veterinary office for treatment.
I understand that Joanne Tamburro
cannot be held responsible for the results of the veterinary treatment or the loss of my pet. All medical information must be released to Joanne Tamburro prior to my dog(s) arrival. This agreement is valid starting on the date below whenever Joanne Tamburro cares for my pets: Pet Owner's Signature: _________________________________Date: ____________________ |
