Veterinarian Release | SCC | senior pet care, Seattle, WA

Client Name
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone
Veterinarian Name
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone
YESNO
If this veterinarian is not available, I authorize SCC to transport my pet to a veterinarian of choice and authorize treatment of said pet.
YESNO
I give permission to provide treatment up to this amount indicate dollar amount above
I hereby relieve the veterinarian and SCC for any responsibility for injury and/or death of my pet which may have been prevented by care beyond the financial limit I have authorized.
AGREE
I assume full responsibility for payment upon my return for all services rendered to my pet at the request of SCC Pet Care
AGREE
This agreement is valid when this form is submitted, until service is terminated.
agree

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~ Charlotte Myers

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