Please complete one form per pet. After you click Submit, you will receive a copy of the completed form to the email address you provided. *Required field. Client InformationClient's Name:* First Last Client's e-mail:* Pet InformationName of Pet:*Veterinarian InformationDo you have a Regular Veterinarian or Pet Hospital?YesNoHospital Name:*Veterinarian Name:*Hospital Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Hospital Phone:*Phone format: (###)###-####Do we have your permission to use our Veterinarian in the event above Veterinarian is not available?*YesNoMedication InformationNumber of medications needed during Pet Service Contract:*Please enter a number from 1 to 5.Medication (1)Name of Medication:*Reason for Medication:*Has pet been on this medication before?*YesNoAmount Given:*Time to Administer:* : HH MM AM PM Does this medication have any know side effects?*YesNoPlease describe known side effects:*Instructions for administration:*Any known problems with administering:*YesNoPlease describe any known problems with administering:*Medication (2)Name of Medication:*Reason for Medication:*Has pet been on this medication before?*YesNoAmount Given:*Time to Administer:* : HH MM AM PM Does this medication have any know side effects?*YesNoPlease describe known side effects:*Instructions for administration:*Any known problems with administering:*YesNoPlease describe any known problems with administering:*Medication (3)Name of Medication:*Reason for Medication:*Has pet been on this medication before?*YesNoAmount Given:*Time to Administer:* : HH MM AM PM Does this medication have any know side effects?*YesNoPlease describe known side effects:*Instructions for administration:*Any known problems with administering:*YesNoPlease describe any known problems with administering:*Medication (4)Name of Medication:*Reason for Medication:*Has pet been on this medication before?*YesNoAmount Given:*Time to Administer:* : HH MM AM PM Does this medication have any know side effects?*YesNoPlease describe known side effects:*Instructions for administration:*Any known problems with administering:*YesNoPlease describe any known problems with administering:*Medication (5)Name of Medication:*Reason for Medication:*Has pet been on this medication before?*YesNoAmount Given:*Time to Administer:* : HH MM AM PM Does this medication have any know side effects?*YesNoPlease describe known side effects:*Instructions for administration:*Any known problems with administering:*YesNoPlease describe any known problems with administering:*Consent To Administer Medications To PetBay Area Pet Pals and staff agree to administer medication to above pet per the instructions listed above. Bay Area Pet Pals is not responsible for any reaction pet has to the medication. If pet needs emergency vet care, owner agrees to be responsible for all cost incurred including transportation and vet fees. Owner agrees to hold Bay Area Pet Pals harmless of any claims unless gross negligence has been proven. This agreement will remain valid until a new agreement has been completed and on file.I have read the information above and have entered the above information as truthfully and accurately as possible.**This consent to administer medications to your pet has no expiration date unless otherwise discussed.AgreeDate MM DD YYYY Initial*Please verify that all information is accurate then, click the Submit button below.CommentsThis field is for validation purposes and should be left unchanged.