Type of Medication. Dosage/Frequency: Location of Medicine: Special instructions? Please describe in detail.
Type of Medication. Dosage/Frequency: Location of Medicine: Special instructions? Please describe in detail. OTHER Favorite game(s): Favorite hiding place(s): Must be kept in/out certain rooms? Yes No If yes, please explain: Location of supplies, cleaning instructions: TV/Radio left on for pet? Yes No If yes, please explain: TRAITS Check the box that best describes your pet’s personality Is friendly with other pets Yes No Likes new adults Yes No Likes children Yes No Is a resource guarder Yes No Afraid of other pets Yes No Is allowed to have treats Yes No Is fearful of noises or other things Yes No Is prone to chewing Yes No Injured self out of boredom Yes No Obeys basic commands Yes No Has bitten people or other pets Yes No Has shown aggression Yes No Gets carsick Yes No Injured self/escaped out of fear Yes No Additional information about habits or behavior that may be helpful Please describe in detail.
Type of Medication. Dosage/Frequency: Location of Medicine: Special instructions? Please describe in detail. OTHER Favorite game(s): Favorite hiding place(s): Location of collar/leash: Special harness/choke collar required for walks? Must be kept in certain rooms? Yes No If yes, please explain: Location of supplies, cleaning instructions: TV/Radio left on for dog? Yes No If yes, please explain: How to transport dog: Backseat Crated Other: TRAITS Check the box that best describes your pet’s personality Is friendly with other dogs Yes No Likes new adults Yes No Likes children Yes No Must stay on leash during walks Yes No Is allowed in the house Yes No Is allowed to have treats Yes No Is prone to digging Yes No Is prone to chewing Yes No Is fearful of noises or other things Yes No Obeys basic commands Yes No Has bitten people or other dogs Yes No Has shown other aggression Yes No Gets carsick Yes No Injured self/escaped out of fear Yes No Injured self out of boredom Yes No Additional information about habits or behavior that may be helpful Please describe in detail.
Type of Medication. When you use a participating retail pharmacy, you pay: When you use the Medco Pharmacy, you pay: Generic drugs $15 co-payment (for up to a 30-day supply) $40 co-payment (for up to a 90-day supply) Brand-name drugs $50 co-payment (for up to a 30-day supply)* $135 co-payment (for up to a 90-day supply)* Deductible (applies to brand-name medications purchased at participating retail pharmacies and through mail order) $200 single/$500 family (per calendar year beginning January 1) $200 single/$500 family (per calendar year beginning January 1)
Type of Medication. Dosage/Frequency: Location of Medicine: Special instructions? Please describe in detail. EXHIBIT B OTHER Favorite game(s): Favorite hiding place(s): Location of collar/leash: Special harness/choke collar required for walks? Must be kept in certain rooms? If yes, please explain: Yes No Location of litter box, supplies, cleaning instructions: TV/Radio left on for pet? Yes If yes, please explain: No How to transport pet: Backseat Crated Other: TRAITS Check the box that best describes your pet’s personality Is friendly with other dogs Yes No Likes new adults Yes No Likes children Yes No Must stay on leash during walks Yes No Is allowed in the house Yes No Is allowed to have treats Yes No Is prone to digging Yes No Is prone to chewing Yes No Is fearful of noises or other things Yes No Obeys basic commands Yes No Has bitten people or other dogs Yes No Has shown other aggression Yes No Gets carsick Yes No Injured self/escaped out of fear Yes No Injured self out of boredom Yes No Additional information about habits or behavior that may be helpful Please describe in detail. EXHIBIT B (Attach list of vaccinations of Pet) EXHIBIT C EMERGENCY CONTACT LIST Name: Phone No.: Relation to Owner: Name: Phone No.: Relation to Owner: Name: Phone No.: Relation to Owner: EXHIBIT D VETERINARY RELEASE Dear : Nellie's Pet Care will be caring for my Pet(s) , beginning on the date below. Nellie's Pet Care will try to contact me as soon as medical care is deemed necessary. However, if I cannot be reached immediately, I authorize you to treat my Pet(s) and confirm that I will be responsible for paying for any emergency treatment when I return. If the above-named veterinarian is not available, I agree that another veterinarian in his or her veterinary group may provide the treatment described above. If neither of these veterinarians is available, or if emergency care is needed after regular veterinary office hours, I give permission for Nellie's Pet Care to take my Pet(s) to the nearest animal hospital or emergency clinic. I understand that Nellie's Pet Care assumes no responsibility for the loss of my Pet(s) and release Nellie's Pet Care from all liability related to transportation, treatment, and expense. My pet[s] have the following health issues: . I do not authorize the veterinarian to euthanize my pet in extreme circumstances under his or her advisement after all reasonable attempts have been made to reach ...
Type of Medication. Dosage Frequency: Location of medicine Special instructions? Please describe in detail.
