Owner's Name: Address: Home Phone: Work Phone: Cell Phone: E-mail: Emergency Contact: Home Phone: Cell Phone: Pet's Name: Breed: Size in Lbs.: Age: Sex: Conditions: Medications: Vet Hospital: Vaccinations/Date: Rabies: Distemper: Kennel Cough (Dogs): Leukemia (Cats): Lyme (Dogs): Fecal check: Transport to?: Date of transport: Date: Time: How did you hear about us? Please read the Liability Release text below. Note that when you hit submit below the text, you agree to the terms of the liability release form. Please call us if you have any questions before you submit. Services Agreement & Liability Release This Agreement dated _____________, by and between Vet Taxi and ______________________ (hereinafter “Client”) is based on the desire of the client to engage the services of Vet Taxi to transport their pet(s) _______________________ to/from a veterinary hospital or boarding facility, and to communicate the content of any veterinary instructions or advice applicable to the pet. Client, hereby, acknowledges and agrees to the following as signified by their initials at the end of each section. Liability Client understands that there are inherent dangers in the transport of animals that is beyond the control of Vet Taxi, and releases Vet Taxi from any liability in the event that their pet becomes injured or dies during transport. _______ Client has informed Vet Taxi of all behavioral traits of their pet that may affect the safety of the pet or the handlers, and hereby releases Vet Taxi for any liability that may arise from any harm resulting from the action of their pet and; furthermore, accepts full responsibility for such actions and consequential damages. _______ Fees Client has been made aware of the fees associated with Vet Taxi’s services and agrees to make payment in full prior to the rendering of services. Additional fees incurred, such as, but not limited to, an extended waiting period at the vet or pet facility will be billed to the client, with payment due upon receipt. ________ Vet Taxi only accepts payments in cash and checks. The Client will be charged $50 for any returned check. ________ Pet Facility Services The Client is responsible for payment of all pet services provided by the pet facility (veterinary, grooming, boarding, daycare, etc.). If payment can not be arranged ahead of time by Client, Client will be available to pay the service provider via telephone (if provider accepts payment by credit card). _______ In order to facilitate services, Client understands that Vet Taxi may be required to provide the pet facility with Client’s personal contact information, including address and telephone; etc. Client hereby authorizes Vet Taxi t provide such information to pet services facility. _______ Client Availability It is important that Client is available for consultation during the period that their pet is with Vet Taxi. This will allow Vet Taxi to contact Client in order to convey additional pet facility services recommended or requested by the service provider, such as elective veterinary procedures. _______ Emergency Procedure Authorization Client hereby authorizes Vet Taxi and its representatives to, at its sole judgment, authorize any emergency veterinary procedures that may be required. _______ Agent Release Authority Client hereby authorizes Vet Taxi and its representative to be owner’s agent on _____________(date) for _____________, and gives Vet Taxi and its representative the authority to sign any liability release, anesthesia release, services agreements, etc. that the pet care facility may require on behalf of the Client. Client understands any document signed on behalf of her/him by Vet Taxi and its representative will hold the same legal binding authority as if signed by the Client. __________ The parties hereby agree to the content of this document effective as of the date first set above. You need Java to see this applet.