While we all hope that nothing bad will ever happen to us or our loved ones, we do know that accidents, sickness, and death can occur. In order to protect your beloved pet(s) and to assist your family members, please take the time to download and complete the Owner Emergency Information PDF by clicking on the link below. You may also right click on the link below and click on 'save target as' and save it on your computer. Your much-loved companion(s) will thank you.
..\Forms\Owner Emergency Information.pdf
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Below is a sample of the form.
EMERGENCY PET INFORMATION
Golden Rescue In Naples, Inc
P. O. Box 770291
Naples, Florida 34107-0291
239-293-8159
mygoldns@yahoo.com
Owner Information
Your Name ______________________________________________________________
Address _________________________________________________________________
City ______________________________________State__________ Zip _____________
Home Phone _________________________ Cell Phone ___________________________
Email ___________________________________________________________________
Your Emergency Contact (Person who may need to know about your situation or who has
information on your condition.)
Name __________________________________________ Relationship _______________
Phone #______________________
Pet Caregiver Information
Primary Emergency Pet Caregiver
Name ____________________________________________________________________
Address __________________________________________________________________
City ________________________________ State _____________ Zip _______________
Home Phone ___________________________ Cell Phone _________________________
Email___________________________________________________________________
Alternate Emergency Pet Caregiver
Name ____________________________________________________________________
Address __________________________________________________________________
City _____________________________________ State ___________ Zip ____________
Home Phone ______________________________ Cell Phone ______________________
Email___________________________________________________________________
(Continued)
www.GRINinc.org
Emergency Phone 239-293-8159Veterinarian
Name ____________________________________________________________________
Address __________________________________________________________________
City ______________________________________State ___________ Zip ___________
Phone __________________________________________________________________
Pet Emergency Care Center – After hours Emergency Care
Name ____________________________________________________________________
Address ___________________________________________________________________
City ____________________________________ State _________ Zip _______________
Phone ___________________________________________________________________
Information for Pet Caregivers
Thank you for agreeing to take care of my pet(s) if due to an emergency, illness or death, I am
unable to do so. My signature below is authorization for veterinarian care and treatment, if
necessary. In the case of any of my pets noted as adopted from GRIN Inc., that organization
must be notified of my condition and will aid in the arrangements for my pet(s). Contact
information for GRINinc is above and below.
Below is most of the information you will need.
Your Name Printed _____________________________________________________
Your Signature ________________________________________________________
Business Information
Pet Health Insurance
If your have a pet insurance policy, please provide the following:
Name of Insurance Company_____________________________________________________
Phone Number_______________________________________________________________
Policy Number_______________________________________________________________
Power of Attorney
If you have a power of attorney for dealing with pet related matters in the event of your
incapacity or death, please provide the following:
Name of person appointed to act in your absence ______________________________________
Telephone number of person named above ___________________________________________
Location of power of attorney document____________________________________________
Trustee Contact Information
If you have a trustee appointed to distribute the assets you have allocated for pet care, please
provide the following information:
Name of Trustee______________________________________________________________
Telephone Number____________________________________________________________
Location of trust or pet estate planning documents: ____________________________________
(Continued)
www.GRINinc.org
Emergency Phone 239-293-8159PET INFORMATION
(Please copy and complete the following pages for each pet.)
Pet’s Name ______________________________________________ Sex _______________
Date of Birth ______________ Has your pet been spayed or neutered? _________________
Breed __________________ Adopted through GRIN Inc? ____Yes (contact GRINinc) ____No
Please indicate if your pet has the following identification:
Microchip ID (Brand) __________________ ID Number_______________________________
License (City or County) ___________________ Tag Number___________________________
Tag with your name, address, phone________________________________________________
If tags/collars are not on the pet, where are they _______________________________________
Identification Marks____________________________________________________________
______________________________________________________________________________
Significant Medical History______________________________________________________
______________________________________________________________________________
Location of Food and Medicine___________________________________________________
Feeding Instructions:
Type and amount of food________________________________________________________
Number of daily feedings & time of day_____________________________________________
Supplements___________________________________________________________________
Types/Names of medications_____________________________________________________
____________________________________________________________________________
Medication Instructions_________________________________________________________
____________________________________________________________________________
Type of flea and heartworm preventative ____________________________________________
Date heartworm preventative is given: ________________ Date flea preventative given _______
Special Needs________________________________________________________________
Behavioral Habits_____________________________________________________________
Please note any verbal or non-verbal commands your pet responds to as well as any body
language used to communicate___________________________________________________
_____________________________________________________________________________
Please outline your pet’s daily routine (walking, eating, sleeping, playing, bathroom habits) ________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Where is his/her leash?_________________________________________________________
Please attach a current photo of your pet. If you may be using this form for emergency purposes
please be aware that a photo of you with your pet is often proof of ownership and will facilitate
reuniting you with your pet should you become separated.
(Continued)
www.GRINinc.org
Emergency Phone 239-293-8159Is your pet housebroken? ________ Is your pet allowed outside off leash? __________________
Is your pet crate trained __________ Does he/she have a crate___________________________
Where are crate(s), toys, etc______________________________________________________
Where does your pet sleep? _____________ Does your pet like other animals? ______________
Does your pet like children? _____________ Where are your pet’s veterinary records located in
your home? _________________________________(please attached most re-cent exam record)
Who will most likely be a permanent caregiver for your pet(s)
Name ____________________________________________________________________
Address ____________________________________________________________________
City _______________________________ State _________________ Zip ______________
Phone # ____________________________ Alternate Phone # _________________________
Other Pertinent Information
Any other pertinent information, other than specific pet care information addressed in the
previous pages, to help others provide for your pet(s) in the event of your disability or death:
______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________
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We never know when an accident, disaster, tragedy, or sudden illness may strike.
Having information and a plan in the ready is one of the most loving gestures
you can give your family and friends should something happen to you. YOU know
your pet(s) needs and he/she is relying on you. Please take the time to fill out this
form for the welfare & safety of him or her.
www.GRINinc.org
Emergency Phone 239-293-8159