Waiver and Consent Form To Take Dog/s To Veterinarian Clinic

Breed:  _________________________________________________________

Name of Dog: ____________________________________________________

Date of Birth & Sex: ________________________________________________

Colour & Markings:  ________________________________________________

Tattoo # or Microchip #:  _____________________________________________

 

___Dental Cleaning

___Spaying

___Neutering

___Anal Gland Cleaning

___Dental Extraction

___Yearly Immunizations Shots

or other procedures that are not listed above:  _______________________________

_______________________________________________________________

I represent that I am the  (1.) Legal owner  (2.) Guardian   for the above named dog.

  1.  As Owner I give my consent to have above named dog to be boarded with Jones Toy Breed Boarding kennel and give permission to Jones Toy Breed Boarding Kennel, its staff, owners or representatives to take the above named dog/s to Barrhead Veterinarian clinic, owned by Dr. Iliya S. Belosevic #780-674-5335.  60006 RR 34, Barrhead, Alberta, Canada for the above procedure/s to be performed.
  2. As Guardian I have been given consent to sign on the behalf for the above named dog to be boarded with Jones Toy Breed Boarding Kennel, its staff, owners or representatives to take the above named dog/s to Barrhead Veterinarian clinic, owned by Dr. Iliya S. Belosevic #780-674-5335.  60006 RR 34, Barrhead, Alberta, Canada for the above procedure/s to be performed.

I give permission to Jones Toy Breed Boarding Kennel, its staff, owners or representatives to sign any waiver that the Veterinarian requires on my behalf.

I have had the opportunity to ask questions regarding the procedure/s above and the risks involved with the Veterinarian or his staff and understand the risks involved in the above procedure/s.

I have talked to the Veterinarian clinic and have arranged payment for the above procedure/s.

I understand that if additional procedures have to be done for the safety and health of the above named dog, that the Veterinarian or staff will contact me.  If they are unable to contact me, I give permission to the Veterinarian to do what is in the dog’s best interest.

I take full responsibility for additional costs which may occur with the above procedures/s.

I have informed the Veterinarian of any sickness or illness that the above named dog have ever had to the best of my knowledge.

With my signature below, I certify that I have read and understood this authorization and consent agreement and waivers.

Signature:__________________________________________________

Print Name:_________________________________________________

Phone Number / Contact Information:_______________________________

Mailing address:______________________________________________

Date______________________________________________________

 

Witness/Received by:___________________________________________

Print Name:__________________________________________________

Date_______________________________________________________