Medical/Emergency Information

Safe & Healthy Pets are Happy Pets!

Owner Information:

Pet Parent

Phone

Pet Parent 2 (Optional)

Phone

Pet Information:

Pet Name

Breed(s)

Sex

Birthday

Month

Day

Year

Colors/Identifying Markings

Microchip Number (if applicable)

Veterinary Information

Veterinarian:

Veterinarian Address

Country/Region

Address

City

Zip / Postal code

Veterinary Office Phone

Health & Medical

Attach Vaccination Records

Current Medications (Name, Dosage, Schedule)

Allergies (Food, Environmental, Medications, Etc.)

Chronic Conditions:

Recent Illness, Injury or Surgery

Flea/Tick Prevention (Brand & Date of Last Dose)

Signs of Stress or Illness to Watch For

Emergency Contact Information:

Emergency Contact Name

Emergency Contact Number

Relation to Contact

Secondary Emergency Contact Name

Secondary Emergency Contact Number

Relation to Contact

Emergency Care Plan

Emergency Instructions

Do we have permission to take pet to vet and make treatment options in the case of emergency if unable to reach you or emergency contact(s)?

Yes

No

If you checked Yes, please fill out the following:

In the event of a medical emergency while my pet is in the care of staff at Premium Paws, I

First name

Last name

authorize the provider to seek veterinary treatment if necessary.

Please select one of the following Below:

I authorize any and all treatment deemed necessary by the attending veterinarian.

I authorize treatment only up to a specific cost amount without prior approval.

I authorize only life-saving treatment until I or my emergency contact can be reached.

If you selected the Second option, please list specified cost limit

$

I understand and agree that in the event of an emergency requiring veterinary care, if I or designated emergency contact(s) cannot be reached, I may be held fully financially responsible for any and all related costs as approved above.

Pet Parent

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.