CANINE BOARDING INSTRUCTION CHECK IN / CONSENT FORM

Owner's Name: *

Address *

City *

State *

Zip *

Email *

example@example.com

Phone *

Patient Name: *

Patient Species: *

Patient Breed: *

Patient Color: *

Patient Age: *

Patient Weight: *

Emergency Contact Name (OTHER THAN SOMEONE TRAVELING WITH YOU): *

Emergency Contact Phone Number: (OTHER THAN SOMEONE TRAVELING WITH YOU) *

Area Code Phone Number

DROP OFF DATE *

Date Hour Minutes AM/PM Option

PICK UP DATE *

Date Hour Minutes AM/PM Option

The category of boarding I RESERVED ALREADY is: *

Regular Runs Deluxe Runs Deluxe Condos Ultimate Deluxe Condos ICU (for puppies, geriatric, seizure pets)

In the past 14 days, has your pet had any? Please check all that apply. *

Coughing Sneezing Vomiting Diarrhea None

If you answered yes to the above question, please explain the coughing/sneezing/vomiting/diarrhea.

In the past 14 days, has your pet visited? Please check all that apply. *

Another boarding facility Another daycare facility A dog park None

If you answered yes to the above question, please explain where and when your pet visited a boarding or daycare facility, or a dog park.

My pet is boarding: *

If your pet is SHARING a reservation, please list who he/she is sharing with:

FEEDING NOTES:

We do require that all dry food be packaged individually in meal portions. We do not have the storage space for containers or commercial bags of food in our kennel. Please use ziplock bags with your pets name in permenant marker on each bag.

FREE FEEDING IS NO LONGER AN OPTION. You must provide meals for your pet.

How often do you feed your pet? *

If you did not MEAL PACKAGE your own food and are feeding Waverly Animal Hospital food, how much do they get fed (in cups) *

What kind of food do we feed? *

IAMS Lamb/Rice IAMS Mini Chunks IAMS Puppy Science Diet Sensitive Skin & Stomach Own Food

When do we START FEEDING your pet? *

Additional Services Requested: (If Exam is requested, please explain as "OTHER" Option)

Bath, Brush, Blow Dry, Nail Trim Nail Trim Anal Gland Expression

Late Walks: Please list each night you would like to add-on a late walk:

Playtimes: Please list each day you would like to add-on a playtime: (this does not include playtimes already included in Deluxe Accomodations):

Please list each Deluxe Daycare Half Days Add-on dates (only available M-F):

Please list each Deluxe Daycare Full Days Add-on dates (only available M-F):

Is my pet currently on medication that needs to be administered here?

If yes, name and dose last given: YOU MUST ALSO COMPLETE THE MEDICATION ADMINISTRATION FORM ON OUR WEBSITE FOR DETAILED INSTRUCTIONS.

Do you need REFILLS of any medications? Please include quantity requested.

Please list any belongings you are bringing for your pet:

IF ANYTHING NONEMERGENCY (NONLIFE THREATENING) MEDICAL PROBLEMS ARISE WHILE BOARDING, I GRANT PERMISSION FOR DOCTORS TO: *

IF ANYTHING EMERGENCY (LIFE THREATENING) MEDICAL PROBLEMS ARISE WHILE BOARDING, I GRANT PERMISSION FOR DOCTORS TO: *

DISCLOSURES:

1. IF MY PET IS COUGHING OR SNEEZING, HAS DIARRHEA OR VOMITING, FLEAS, OR ANYTHING POTENTIALLY CONTAGIOUS, AN EXAM AND/OR TEST(S) WILL BE PERFORMED. IF MY PET IS FOUND CONTAGIOUS, TREATMENT IS REQUIRED FOR THE SAFETY OF THE OTHER ANIMALS AND STAFF. I AM AWARE THAT I AM RESPONSIBLE FOR ANY FEES ASSOCIATED WITH DIAGNOSING AND TREATING MY PET.

2. SHOULD MY PET CONTRACT INFECTIOUS TRACHEOBRONCHITIS DURING OR AFTER THEIR STAY, WAVERLY ANIMAL HOSPITAL, BOARDING & GROOMING WILL NOT BE HELD RESPONSIBLE AS THIS AN INHERENT RISK OF ANY KENNEL ENVIRONMENT.

3. I UNDERSTAND IF I SELECT "CALL FIRST", AND I CAN NOT BE REACHED, MY PET WILL BE TREATED AND I AM RESPONSIBLE FOR ANY FEES ASSOCIATED WITH DIAGNOSING AND TREATING MY PET.

4. I ACKNOWLEDGE THAT MY PROPERTY MAY BE DAMAGED OR LOST DURING BOARDING, DAYCARE, OR HOSPITALIZATION. I WISH, HOWEVER, TO LEAVE THE PROPERTY DESCRIBED BELOW WITH WAVERLY ANIMAL HOSPITAL ANYWAY. I ACCEPT ALL RISK OF LOSS AND DAMAGE TO PROPERTY LEFT, I RELEASE THE BUSINESS FROM ALL LIABILITY ASSOCIATED WITH THE LOSS OR DAMAGE TO MY PROPERTY AND I WILL NOT HOLD WAVERLY ANIMAL HOSPITAL RESPONSIBLE FOR LOSS OR DAMAGE TO MY PROPERTY.

5. I UNDERSTAND I WILL BE PROVIDED WITH AN ESTIMATE FOR MY PETS STAY, AND THAT IF MEDICAL CARE IS ADDED, THE STAFF WILL PROVIDE AN ADDITIONAL ESTIMATE OVER THE PHONE. I ALSO UNDERSTAND THAT THE ESTIMATES MAY NOT BE EXACT AND SERVICES/MEDICATIONS ARE SUBJECT TO CHANGE.

6. I UNDERSTAND THAT IF MY PET IS MEDICATION, AT MY REQUEST OR DUE TO ILLNESS, THAT THERE IS A $4.25 CHARGE FOR A TECHNICIAN TO ADMINISTER MEDICATION, PER TREATMENT TIME/DOSE.

7. TO PROVIDE A HEALTHY ENVIRONMENT AND PREVENT THE SPREAD OF DISEASE AMONG PETS IN OUR FACILITY, WE REQUIRE DOGS TO BE VACCINATED BY A VETERINARIAN FOR RABIES, DISTEMPER, HEPATITIS, LEPTOSPOROSIS, PARVOVIRUS, PARAINFLUENZA, HAVE A NEGATIVE FECAL SAMPLE WITHIN THE PAST 12 MONTHS, AND A BORDETELLA/KENNEL COUGH VACCINATION WITHIN THE PAST 6 MONTHS. IT IS HIGHLY RECOMMENDED THAT ALL VACCINATIONS BE UP TO DATE AT LEAST 7 DAYS IN ADVANCE OF DROP OFF.

8. IF YOUR PET IS DUE FOR VETERINARY SERVICES DURING ITS STAY FOR ANY OF THE ABOVE WELLNESS SERVICES, AND/OR RECORDS WERE NOT BROUGHT/SENT IN PRIOR TO OR AT CHECK-IN, TO SHOW PROOF OF BEING DONE ELSEWHERE, YOUR PET WILL BE VACCINATED/TESTED IN ACCORDINANCE WITH OUR POLICY, AND ADDITIONAL CHARGES WILL APPLY AT PICKUP THAT I AM RESPONSIBLE FOR.

Initial that you have read, and agree to, the DISCLOSURES above. *

Clear

I have the completed the form and all information provided is accurate as of the drop off date, despite the date I may be completing the form. If any changes need to be made at check-in, it is my responsibility to mention in to check in staff.

SIGNATURE *

Clear