Date: 

E-mail: 

Emergancy Contact: 

Phone: 

Date of Pick-up: 

Required Vaccine/Exams:
Dogs: Rabies, Parvo, Bordatella
Cats: Rabies

Is your dog on heartworm prevention?    Yes  No

What kind: 

Would you like your pet bathed on the day of pick-up?    Yes  No
If yes, please pick-up after 2 p.m.

Is your pet on a special diet? 

Please list all medications, dosages, and when next dose is due:

Please list all toys, foods, other items left with animal:

There will be an additional charge for baths or if medication needs to be administered during your pet's stay. (This does not include daily heartworm prevention or vitamins.) I also understand that there will be an additional charge to treat any boarding animal found to be infested with fleas or ticks.

I understand that medical problems may arise in my absence. Should the hospital not be able to reach my emergency contact within a reasonable period of time, I authorize the attending veterinarian to administer the minimum medical treatment required to ensure the health and safety of my pet. I will also assume full responsibility for any expenses incurred therein.

I have read the boarding requirements and understand the hospital's policies.

Owner or agent: 

Date: 

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