Veterinarian Information

Veterinarian:*
Hospital:*
Address*
Street Address City State ZIP Code
Phone*
To The Hospital
In Balance Dog is contracted to care for my pet(s) and has my permission to have them medically treated in case of an emergency. In Balance Dog will make all attempts to contact me if medical care is necessary. In the event I cannot be contacted, I authorize you to treat my pet(s) and will be responsible for payment of any fees or services render. Please keep a copy of this form with my pet(s) records.
Pet Owner:*
First Last
Address*
Street Address City State ZIP Code
Mobile Phone*
Mobile Phone*
Pet(s) Name:*
Previous Health Conditions, if any:
I Agreee*
- *If the veterinarian of my choice is not available, I agree that another vet in his/her practice may care for my pet(s). If neither of these veterinarians are available, I give permission for In Balance Dog to take my pet(s) to the nearest animal hospital or emergency clinic.
*You must agree before you will be able to submit this form!
I give In Balance Dog permission for treatment up to*
I Agreee*
- *I understand and Acknowledge that In Balance Dog assumes no responsibility for the loss of any pet and is released from all liability related to transportation, treatment and expense.
*You must agree before you will be able to submit this form!
I Agreee*
- *This release does not have an expiration date and is valid until further notice.
*You must agree before you will be able to submit this form!

Download Options:

Click Here to download, print and send form in through regular mail!

To The Hospital