Client Information Form - Mom & Me Delivery LLC

Date of Pick-Up: *

Time of Pick-Up: *

Address of Pick-Up: *

Name of Contact Person at Pick-Up: *

Contact Person Phone #: *

Name, Age, Sex, Breed, and Approximate Weight of Animal(s) Being Transported: *

Requested Delivery Date and Time: *

Destination Address: *

Name of Person at Drop-Off: *

Phone Number: *

Feeding Routine: *

*Please send enough food (that the pet is used to eating) for travel days plus a couple extra days (in case of emergency delay).

Medical Information: Please include any medical issues and medications (with instructions) that may need to be administered. *

Medical Consent and Release: *

In the event that the pet(s) described herein become ill or injured and require veterinary care, I hereby authorize Mom & Me Delivery LLC to seek medical treatment from a licensed veterinarian. I will take full financial responsibility for all charges incurred. If Mom & Me Delivery LLC is unable to reach me, I authorize them to arrange for any emergency treatment deemed necessary for the well-being and health of the pet(s). My typed name above acknowledges that I have read and understand this document, and agree to hold Mom & Me Delivery LLC harmless from any illness or injury of my pet during or after transport.

Any additional notes that you would like us to be aware of: