estimated birthdate acceptable, must be same as with your vet.
Place "X" between mixed breeds, or "?" if they're a mystery mutt!
If none, leave blank.
if not registered with your town/SCRD, leave blank.
Option for a relative, friend, etc. to be contacted only if primary and secondary numbers are unsuccessful, in case of emergency ONLY.
Select all that apply.
name & last dosage.
Choose all that apply
Select all that apply.
Select all that apply.
Select all that apply.
This waiver will be printed and brought to your home for you to sign in person. Agreeing to the terms above on this form is an agreement of the terms in their entirety. Hard copy signature will be used in the case of an insurance claim only.
If different from $500.00, please fill in above, otherwise, leave blank.