Pet Relinquish Form

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Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Pet's Name

Release (i)

As owner or agent, I agree to turn over said pet, as described above, to the care of Animal Hospital of Lake Villa. It is my understanding that Animal Hospital of Lake Villa will use all care and concern in making medical judgments as to the disposition of this animal, including but not limited to: Treatment, finding a new home or euthanasia if necessary. I agree to pay all charges incurred up to this point and/or relinquished pet fee.

Release (ii)

I understand that this means that I will not receive my pet back now, or in the future. I accept no further responsibility for this animal and willingly release it to Animal Hospital of Lake Villa. I understand that Animal Hospital of Lake Villa will likely release my pet to a local rescue that can find a new home to take care of this pet in the future.

Date

Signature

Clear Signature

Animal Hospital of Lake Villa
101 S. Milwaukee Ave.
Lake Villa, IL 60046

Phone: (847) 356-8387
Text: (847) 356-8387
Fax: (847) 558-2606

Premier Veterinary Group
Emergency: (847) 548-5300