** IN CASE OF EMERGENCY **

All costs associated with the proper care of this animal will be paid
in full by the undersigned.  This includes, but is not limited to all
veterinary costs and board at a private boarding facility.


Name of Pet: ________________________________

Type of Pet: _________________________________

Veterinarian Name: ___________________________________

Veterinary Practice: _____________________________________

Veterinarian Phone #: ___________________________________

Microchip Company: _______________________ # __________________________

Name(s) of Owner(s): 

_______________________________________________________________________


Address: ______________________________________________________________


Phone #: ______________________________________



_________________________________
Signature	                 ______________________________________
                                 Signature


Emergency Contact:___________________________Relationship:_____________


Phone #: ____________________________________


Address: ______________________________________________________________