Veterinary Instructions and Release Form
Dog's Name
Description of dog
Dog's birth date or approximate birth date
List all current medical conditions / medications:
If the above named dog becomes ill or is injured, I request that Valerie S. Kneppel take my dog to:
If the above listed vet is not open/available, please provide alternative vet information:
I give permission to Valerie S. Kneppel 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 neither of the veterinary offices named above is available or is farther than the pet’s condition will allow for travel, I authorize Valerie S. Kneppel to take my pet(s) to another veterinary office for treatment.
I understand that Valerie S. Kneppel cannot be held responsible for the results of the veterinary treatment or the loss of my pet.
This agreement is valid starting on the date(s) Valerie S. Kneppel cares for my pet(s).
Date this document is signed
Your Signature
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