In Case Of An Accident: Form

Date: ____________________________

In the event that I, ________________________________,
am incapacitated and unable to make my wishes known regarding
my dog(s), please honor the following requests:

_____________________________ is to be contacted as soon as possible
at the following phone number(s)

____________ (home) or _________________ (work).
You can call collect and mention my name.

If ________________ cannot be reached, contact ____________________

at phone number: __________________________ or ______________

at phone number: ________________ (home) or _______________ (work).

If the dog(s) are not injured, they are to be cared for by the nearest reputable
boarding kennel, and be kept in the best possible manner, until such time that
arrangements can be made for their transport home. The dogs eat

______________________________. My husband (wife) will pay the bill.

If the dog(s) are injured, they are to be cared for by the nearest reputable veterinarian.

I, prefer that my veterinarian, Dr. ___________________at phone #_________________
be contacted regarding decisions on the dog(s) care and treatment. If any dog is injured
beyond all hope of recovery, that dog is to be humanely euthanized.

Photographs and descriptions of the dog(s) are attached, along with their health records.
The dog(s) are micro-chipped with the following identification numbers:

Name:______________________________ Chip # or Tattoo number: ____________

Call name: ________________________

(HT_______, Wt________, describe coloring) Rabies Tag #:

Breed: Kerry Blue Terrier

Name:______________________________ Chip # or Tattoo number: ____________

Call name: ________________________

(HT_______, Wt________, describe coloring) Rabies Tag #:

Breed: Kerry Blue Terrier

The welfare of my dog(s) is my primary consideration.

Name: ______________________________________

Address: ____________________________________

Phone: ______________________________________

Signature: ____________________________________

Enclose in envelope: recent pictures with information printed on back of picture.

Last Updated: 12/15/2002, 11:58 am