OPAAT Emergency Medical Release Form

I, ______________________________ give permission to One Paw At A Time

to seek emergency medical attention for my pet (name) _____________________.

I, ___________________________________ will be responsible for all costs incurred

for the treatment of my pet (name) _____________________________________.

Name ______________________________________________________________

Address _____________________________________________________________

City __________________________________ State ______ Zipcode ___________

Home Phone __________________________ Business Phone _________________

Cell Phone ______________________________