4pawsllc
Designer pet suites and social daycare for your furry family
Pet’s First Name:
Last Name:
Is your pet allergic to any human food or other pets?
Medication name:
For what condition is the pet being treated?
Is there any special way that you give your pet medication?
Verify medication count of prescription meds only:
Ointment Count:
Oral Count:
Other (Specify Count):
Is this medication to be administered regularly or on an as-needed basis?Regularly scheduled
AM Amount:
Noon Amount:
PM Amount:
As Needed
If you selected “As Needed,” specify the max amount daily dosage/frequency:
By signing, I give permission to administer the above medications or supplements to my pet at $4 per day per pet charge.
Pet Parent Signature:
Date:
Please fax records requested below as soon as possible to 4 PAWS, LLC (725) 234-0865
Vet:
Fax:
Pet Parent Information:
Name:
Email:
Address:
City, State, Zip Code:
Best Cell Phone Number:
Pet name and breed:
Please include copies of:
Vaccination recordsLab or pathology reportsExam ReportsSurgery ReportsX-Ray ReportsEntire Medical Record
I hereby certify that I am the owner of the above-described pet. Further, I hereby request and authorize this veterinarian to release the requested medical information for my pet to 4 PAWS, LLC and its successors. I release the veterinarian and staff from any legal responsibility or liability for the release of information to the extent indicated as authorized herein. This authorization expires 90 days from the date of signature. I understand I may revoke this authorization, but the revocation may not be applied retroactively once the information specified herein has been released.
