Dr Kay Pitkeathly BVSc
109 Billa Road, Corner Menai Road, Menai NSW 2234
Telephone: (02) 9541 1455 Fax: (02) 9543 1756
menaivet@menaivet.com.au
Permission slip
I ……………………………give permission for my child……………………………………..to experience
the vet / vet nurse for a day at Menai Animal Hospital, 109 Billa Rd, Bangor, NSW, 2234, between the
hours of 11am – 3pm,
Child’s Age:………………
Reason: Vet for a Day on ……………/9/14
11am to 3pm
Please bring a drink and a packed lunch (e.g. sandwich)
Pleased wear closed toe shoes
Allergies:………………………………………………………………………………………………
Medical condition:…………………………………………………………………………………….
Contact details:…………………………………………………….
Parent/Guardian…………………………………………………………………………………………………
Secondary Emergency Contact if parent/ Guardian is not
contactable…………………………………………………………
Menai Animal Hospital
Participant Declaration
By booking I declare that:
1. My child will not damage, deface or remove anything that is part of the Menai Animal Hospital.
2. My child will remain on the premises of the Menai Animal Hospital till collected by parent /
guardian at 3pm, unless a written permission note provided saying can walk home or is being
collected by someone else.
3. Realising that every care will be exercised, I hereby indemnify Menai Animal Hospital and its owner
and employees against all actions, suits, claims and demands [including costs] for personal injury or
damage to, or loss of, personal property incurred as a result of my child’s attendance at vet for a day
program at Menai Animal Hospital.
4. I give Menai Animal Hospital authority to use and reproduce any photograph taken of me or my
child for any purpose including display and sale by or on behalf of the Menai Animal Hospital
without any compensation to me.
In the case of accident or emergency, I give permission for treatment by a doctor, hospital or by ambulance
service. I agree to bear any costs incurred.
The information I have provided on this form is true and correct.
Parent/Guardian
Name……………………………………………………………………………………………………….
Parent/ Guardian
Signature…………………………………………………………………………………………………