Emergency Contact & Medical Release Form

Emergency Contact & Medical Release

Please complete, digitally sign, and submit the Emergency Contact and Medical Release Form.

Waggin' Tail Inn Medical Information and Release

Name *

First and Last Name

Phone *

Email Address *

Dog's Name *

Dog's Breed *

Dog's Gender *

Male

Female

Is your dog Spayed or Neutered *

Yes

How old is your dog? *

List any allergies that your dog may have: *

List any Medications that your dog is currently taking: *

Does Your Dog have any special needs: *

Veterinarian *

Veterinarian's Phone Number: *

Name of Emergency Contact in case you cannot be reached *

Phone Number of Emergency Contact (please include the area code)

Emergency Consent: *

I understand and agree to the Emergency Consent Information outlined below::

In the event of a medical emergency, I give Evonne Kucera of the Waggin’ Tail Inn permission to seek necessary veterinary care for my dog, listed above.
I understand that I will be consulted before care is sought if possible and that I will be notified at the earliest possibility.
I also understand that I will be responsible for the cost of necessary care.

Signature

Clear

Print Your Name *

Date *

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