Please print out this form, fill in the information and bring it with you on your first visit.

www.doggienanny.com

VETERINARY INSTRUCTIONS AND RELEASE FORM

Pet’s Name:__________________________________________________________ 
Description:_______________________________________________Age:_________
Medical conditions/medication:_____________________________________________
_____________________________________________________________________

Pet’s Name:___________________________________________________________ 
Description:_______________________________________________Age:_________
Medical conditions/medication:_____________________________________________
______________________________________________________________________

If the above named pet(s) becomes ill or is injured, I request that The Doggie Nanny Inc.
take the pet to:

Veterinary Office Name:______________________________________________________
Address: ___________________________________________________________________
Phone Number: _____________________________________________________________

TO THE VETERINARIAN/CLINIC/HOSPITAL:

During my absence, a representative of Doggie TLC Inc./ DBA The Doggie Nanny 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 Doggie TLC Inc./ DBA The Doggie Nanny
to approve treatment up to $ __________________

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 Doggie TLC Inc./ DBA The Doggie Nanny to take my pet/s
to another veterinary office for treatment.
I understand that Doggie TLC Inc./ DBA The Doggie Nanny cannot be held responsible for
the results of the veterinary treatment or the loss of my pet.
I also agree that Doggie TLC Inc./ DBA The Doggie Nanny is released from all liability
related to any prior medical condition my dog(s) had/has that would cause him /her
to get easily injured or ill.

All medical information must be released to Doggie TLC Inc./ DBA The Doggie Nanny prior
to my dog(s) arrival. This agreement is valid starting on the date below whenever Doggie TLC Inc./
DBA The Doggie Nanny cares for my pets:

Pet Owner's Signature: _________________________________Date: ____________________