Dog Information Form Dog Information Form DOG INFORMATION PET DETAILS Pet Name * Pet Gender * Colour * Date of Birth * Neutered/Spayed * Yes No Microchip Number * OWNERS DETAILS Owner Name * Owner Name First First Last Last Address * Email * Contact Number * EMERGENCY CONTACT DETAILS (if we can not get in contact with owner) Contact Name * Contact Name First First Last Last Contact Number * Email * Address * REGISTERED VETERINARY DETAILS Practice Name * Contact Number * Address * INSURANCE DETAILS Insurance Company * Policy Number * Contact Number * MEAL, BEHAVIOURAL & SLEEPING ARRANGEMENTS MEAL PORTIONS * BEHAVIOUR AND MEDICAL REQUIREMENTS * SLEEPING ARRANGEMENTS * ADDITIONAL INFO * VETERINARY RELEASE KNOWN MEDICAL CONDITIONS * FOR ATTENTION OF THE VETERINARY PRACTICE Black & Tan Dachshund Boarding are caring for my dog during my absence. I hereby authorise you to administer medical treatment to my dog. I give Black & Tan Dachshund Boarding permission to transport my dog to the Veterinarian stated above and authorise treatment needed in the event of an emergency or sickness. I also authorise Black & Tan Dachshund Boarding to transport my dog to any other Veterinarian practise they see fit and authorise treatment. If emergency care is required out of hours, I authorise for my dog to be taken to the nearest available practice. I give permission for Black & Tan Dachshund Boarding to approve treatment up to * (amount / no limit). I agree to authorise the Veterinarian to euthanise my dog in extreme circumstances after all reasonable attempts have been made to reach me or my emergency contact. In the event of death, I would like my dog to be: * Cremated Kept at Vet Other: To the best of my knowledge, the above information is correct and accurate. I agree to be responsible for all charges, not limited to: vet fees, extra visit fees and transportation. I agree that Black & Tan Dachshund Boarding is released from all liability related to this medical visit. SIGNED * DATE * Submit If you are human, leave this field blank.
