Northern Animal Clinic

5411 North Saginaw Road
Midland, MI 48642

(989)631-9740

www.northernanimalclinic.com

Pet Care Release Form

This form will authorize Northern Animal Clinic to provide veterinary treatment for your pet  while under the care of someone other than yourself. Your pet must be a current patient of Northern Animal Clinic (examined within the previous year) to be eligible.

In the event of an emergency the caregiver named below has my permission to transport my pet(s) to Northern Animal Clinic for veterinary care and treatment. I have provided an emergency contact number. In the event that I am not available, the named caregiver has my permission to initiate treatment.

Pet Care Release Form

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Home Phone (required)
Phone TypePhone Number (required)
Cell or Emergency contact Phone (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Pet's Name(s) (required)

In the event that veterinary care is needed, I will provide payment by: (required)
Credit Card
Caregiver to pay balance
Check left with caregiver
Caregiver Information
Caregiver Name (required)

Caregiver Phone (required)
Phone TypePhone Number (required)
Dates Away (required)

Authorized treatment amount (if I cannot be reached) (required)

Type your name as an electronic signature (required)


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