HIPAA – Four Paws Playground

Attention Veterinarian Office & Emergency Veterinarian, I, the Dog Owner*

Dog(s) Information*

Dog Licensed First and Last Name	Dog Breed

Consent*

I give my permission to Four Paws Playground to act as my agent in the event that Four Paws Playground deems my dog in need of medical attention while under the care of Four Paws Playground.

I further agree that I will be responsible for any and all charges and authorize the following expenses as needed for my dog(s) well-being.

In the event of a terminal illness or a senior dog, the owner or guardian needs to notify their vet that the dog is staying with Four Paws Playground. The owner needs to make arrangements or their wishes known to their vet before staying with us.

I hereby authorize Four Paws Playground to obtain a faxed or mailed copy of my dog(s) vaccinations and medical health records.

This authorization shall be in effect while the dog(s) listed above are in the care of Four Paws Playground.

CHECKING THE BOX INDICATES THAT YOU HAVE READ AND APPROVE OF THE AUTHORIZATION FOR USE, DISCLOSURE OF HEALTH INFORMATION, AND MEDICAL TREATMENT POLICY.

I agree to the privacy policy and I understand this will cover all and any future dogs that I may own.

Name*

First Last

Date*

Signature*

Please type your name above to act as your signature.

Signature

Phone

This field is for validation purposes and should be left unchanged.