This form should be filled out, signed, dated, and turned into your vet. Please keep a copy for your own records. A copy should
also be forwarded to Tip of Tex K-9 Rescue
.
I _____________, hereby give Tip of Tex K-9 Rescue permission to obtain any and all medical records or information
regarding _____________, previously known as ___________. The said Dog has been adopted from our Rescue Group on
________, day of ________, 2004.
Tip of Tex K-9 Rescue has set forth certain policies regarding the health and medical care of said dog. The adopter has agreed
to the terms and conditions, furthermore the adopter hereby gives permission to __________________ DVM, to release
Medical updates.
Procedures needed for said dog.
(Please check all that apply)
___ Spay
___ Neuter
___ Rabies Vaccination
___ Parvo Vaccination
___ Distemper Vaccination
___ Canine Adenovirus Vaccination (hepatitis)
___ Canine Para influenza Vaccination
___ Initial series of puppy Vaccinations
___ This dog is Heartworm +
Other: ____________________________________________________________________
_________________________________
Adopters Signature
_________________________________
Adopters Name
_________________________________
Date
_________________________________
Approved By
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