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Authorization for Veterinary Care
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I am the lawful owner, and I have voluntarily given temporary custody of my dog to Michael LaMantia. If my dog suffers an injury or becomes ill and requires immediate veterinary attention while in his care, I authorize him to take immediate action and seek veterinary care with my veterinarian or any veterinarian of his choosing. I also understand that I am financially responsible to pay for all services rendered.
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Name of Dog Owner:
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Name of Dog:
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Breed / Age:
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Address:
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Phone:
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Email:
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Primary Veterinarian:
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Address:
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Phone:
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Email:
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With my signature below, I authorize Michael LaMantia, to take all actions necessary to seek professional veterinary care for my dog. My signature also certifies that my dog is up to date on all standard vaccinations and immunizations.
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date:
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My signature also certifies that I agree to WAIVE & RELEASE all liability and hold harmless Michael LaMantia, his volunteers, his subcontractors and, in perpetuity, waive any claim for any injury, death or damage to me, my child(ren), my pet(s) or my personal property as a result of my association and participation with his temporary custody of my dog.
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