Name

Date

In the event of illness or injury, I authorize Nitengale Paws to: In the event of illness or injury, I authorize Nitengale Paws to: Contact my preferred veterinarian Seek emergency veterinary treatment if I cannot be reached

Preferred Veterinarian Clinic Name:

Clinic Phone Number:

Emergency Contact (Other Than Owner)

Emergency Contact Phone Number:

I understand all veterinary expenses are my responsibility. (SIGNATURE SIGN/TYPE)