Client's Name* First Last Patient's Name* Please select the SCAN practice to which patient will be transferred to/from.*NAPLESCLEARWATERI, the undersigned owner or authorized agent of the owner of the above pet, desire to use Specialists in Companion Animal Neurology’s (SCAN, LLC) transportation service for my pet's benefit and my convenience and, thus, consent to have the above-named pet transported to and/or from another veterinary facility for ongoing veterinary care and/or observation. I have been advised by staff that: SCAN, LLC's transportation service is not a fully equipped ambulance service;* I Agree The vehicle used is not equipped to provide full medical treatment or care to this pet during transport; and* I Agree SCAN LLC’s employee(s) who will provide such transportation is/are not capable of providing medical treatment or care for my pet during this travel period. I accept and agree that a veterinarian will not be accompanying my pet during the transport;* I Agree I have been advised that the SCAN, LLC employee(s) who will provide this transportation service will use a vehicle owned by SCAN, LLC to provide this transportation and hereby consent to such action;* I Agree I have been advised and consent to the fact that my pet will be transported in a cage, unless he or she is too large for same, in which case he/she will be restrained via some other appropriate means. I accept that my pet may be transported with other animals in the vehicle (each in individual cages or separately restrained).* I Agree I HEREBY WAIVE, RELEASE, AND DISCHARGE SCAN, LLC AND ITS OWNERS, AGENTS, OFFICERS, EMPLOYEES, OR VOLUNTEERS FROM ANY AND ALL LIABILITIES THAT RESULT IN INJURY TO, OR THE LOSS OF MY DOG(S), OR ANY OTHER PROPERTY OF MINE WHICH ARISES IN ANY WAY OUT OF THE TRANSPORTATION PROVIDED BY SCAN, LLC. Digital Signature* Date*
