Pet-Care-Promise-Claim

[vc_normal_text first_section=”yes” title=”Pet Care Promise Claim”][/vc_normal_text]

"*" indicates required fields

I authorize the release of my pet's medical records to Bark-A-Bout.*

Yes, I authorize the release of my pet’s medical records to Bark-A-Bout.

No, I do authorize the release of my pet’s medical records to Bark-A-Bout.

Policy Number

Owner Name*

First Last

Pet Name*

First

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reason For Vet Visit*

Illness

Injury

What injury or illness did your veterinarian diagnose?*

A diagnosis is the medical condition treated. Please do not list symptoms (for example, Limping. Lameness or infections are symptoms of injuries or illnesses). Your veterinarian can help you with the diagnosis. Include a copy of your pet’s treatment records and lab results for this visit if there is more than one diagnoses being treated, your pet stayed at the hospital overnight, or the diagnosis has not been determined.

Treatment Date, From:*

Treatment Date, To:*

Veterinarian Name*

First

Veterinarian / Hospital Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Invoice Total* ($):*

*You must submit itemized invoices with your claim form to medical@barkabout.net. Please do not send estimates.

Signature*

By signing this Claim Form, I confirm that to the best of my knowledge, the information I have provided is true and correct. I authorize the release of my pet’s medical records to Bark-A-Bout.