Today's Date Date Format: MM slash DD slash YYYY Pick Up Date Date Format: MM slash DD slash YYYY Pick Up Time : HH MM AM PM Owner*Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Emergency Contact*Phone*Pet #1 Name*Sex*Breed*Medication Required?YesNoPet #2 NameSexBreedMedication Required?YesNoEmail* Pet's Belongings (Carrier, Toys, Etc)Special InstructionsInclude Medication, Directions, Feeding Direction, and Anything you wish the Doctor to check forFor Your Pet's HealthVACCINATION POLICY: DogsTo insure the protection of all pets under care, the following MUST be up-date: Rabies DHLPPC Bordetlla Fecal Exam(Stool exam within last 6 months) VACCINATION POLICY: CatsTo insure the protection of all pets under care, the following MUST be up-date: Rabies FVRCP FELV Fecal Exam(Stool exam within last 6 months) If NOT up-to-date, or unable to provide proof of vaccination, I give my permission to update my pet(s) vaccinations in accordance with the above policy. Due to our boarding facility policy, your pet has to receive a flea/tick Dip at the beginning of its boarding, and a Bath/or Grooming, at the scheduled pick up time at an additional charge. MEDICAL ILLNESS POLICY*One of the advantages of boarding your pet(s) at the veterinary clinic or hospital is that veterinary attention is readily available should the need arise. If your pet(s) becomes ill, we will call the emergency number listed above regarding your pet’s symptoms, treatment options and estimate of additional costs.If no one can be reached however, please indicate your wishes below by writing your initials, should your pet(s) require any treatment to relieve immediate discomfort or to resolve an important medical condition. Please perform whatever services the doctor deems necessary for the best of my pet until someone can be reached. This includes only non-elective treatment and necessary diagnosis DO NOT administer any medical treatment until specific authorization is given. Reasonable precautions will be used against injury, escape, death of your pet(s). The clinic and staff will not be held liable for problems that develop provided reasonable care and precautions are followed. I also understand that there is no medical staff overnight, only during office hours. I have read and understand this agreement. I fully intend to pick up my pet(s) on the above specified date, if my circumstances should change, I will notify the veterinarian of a new pick up date.Date* Date Format: MM slash DD slash YYYY Owner / Agent*CAPTCHAEmailThis field is for validation purposes and should be left unchanged.