Veterinary Release If you have more than one pet, please complete a separate form for each. Client Name * First Name Last Name Email * Pet Name * DOB If exact DOB is unknown, just year is fine. Breed * Medications and Conditions * Please include anything that you think may be relevant. Veterinary Office Name * Veterinary Office Phone * (###) ### #### Veterinary Office Address * Address 1 Address 2 City State/Province Zip/Postal Code Country TO WHOM IT MAY CONCERN - I hear by authorize the attending veterinarian my pet as listed above and I accept full responsibility for all fees and charges incurred in the treatment of my pet. No Dog Left Behind and its representatives are authorized to transport my pet to and from the veterinary clinic for treatment. If I cannot be reached in case of an emergency, No Dog Left Behind and its representatives shall act on my behalf to authorize any treatment. * I Agree I give permission to approve treatment up to: * $ I will assume full responsibility for payment and/or reimbursement for veterinary services rendered up to the above stated amount. * I Agree By typing my name below I understand and agree that this will be considered my electronic signature. * Please type your full name Today's Date MM DD YYYY Thank you!