BOARDING CHECK IN / CONSENT

I understand that this form is ONLY TO PROVIDE INSTRUCTIONS DURING MY PETS STAY. Please initial stating you have contacted the office and made a reservation PRIOR to filling out this form. *

INITAL CONFIRMING PRIOR RESERVATION HAS BEEN MADE

Pet's Name: *

Gender: *

Species: *

Breed: *

Color/Markings: *

Age: *

Approximate Weight: *

Owner's Name (First and Last): *

Address: *

City: *

State: *

Zip Code: *

Phone: *

Emergency Contact (OTHER THAN OWNER) Name: *

Emergency Contact (OTHER THAN OWNER) Phone Number: *

Area Code Phone Number

Email Address: *

example@example.com

Drop Off Date & Time: We request that you check-in/drop off your pet after 1pm. *

Date Hour Minutes AM/PM Option

Pick Up Date & Time: We request that you check-out/pick up your pet prior to 1pm (except Sundays). *

Date Hour Minutes AM/PM Option

What accommodations did you book for your pet? *

Regular Run Deluxe Run Deluxe Condo Ultimate Deluxe Condo ICU (not fully vaccinated pets, i.e. puppies, kittens, geriatric pets)

While my pet is boarding I would like them to my other pet(s) who are named blanks. (Separate pets names with a comma)

What would you like us to feed your pet during their stay? *

Iams Lamb and Rice Iams Mini Chunks Puppy Chicken and Corn Science Diet Sensitive Skin and Stomach Own Food - PLEASE PRE-PORTION MEALS FOR YOUR PET

How much would you like us to feed your pet? *

How many (of the standard 8oz) cups would you like us to feed your pet each meal? If feeding your own food, we request that you pre-portion "meal bags" (ziplocks) for each feeding *

Please round to the nearest 1/4 cup using decimals (0.0, 0.25, 0.5, 0.75), as needed.

How often would you like us to feed your pet? *

When would you like us to start feeding your pet? *

Date Hour Minutes AM/PM Option

Would you like any additional treatments?

Bath, Brush, Nail Trim Anal Gland Expression Nail Trim Veterinary Exam

Health concerns for exam:

Would you like to add on any additional play times ($10 each)? Specify Dates:

Would you like to add on any late walks ($5 each)? Specify Dates:

Is your pet interested in full day deluxe daycare ($35 each)? Specify Dates (ONLY AVAILABLE MONDAY-FRIDAY):

Deluxe daycare is group play with other dogs that have passed 3 trial sessions

Is your pet interested in 1/2 day deluxe daycare ($20 each)? Specify Dates (ONLY AVAILABLE MONDAY-FRIDAY):

Deluxe daycare is group play with other dogs that have passed 3 trial sessions

Is your pet on any medication that need to be administered during their stay? *

If you answered YES please fill out the BOARDING MEDICATIONS FORM on the website

Please list the medication, the dose and the date and time last given.

I am aware of a $4.25 fee Medication Administration fee each time a technician treats my pet. This is charged per dosing, not per medication (Ex: three pills given at 7am, would be one fee). *

Please initial for medication administration fee awareness

Would you like any refills on any medications? *

Name and quantity of any refills (including food and/or preventatives):

In the past 7 days has your pet had any of the following: *

Coughing Sneezing Vomiting Diarrhea None of the above

If yes, please explain:

IF YOUR PET IS COUGHING, HAS DIARRHEA, OR FLEAS WHILE HERE, AN EXAM AND/OR TEST(S) WILL BE PERFORMED. IF YOU PET IS FOUND CONTAGIOUS, TREATMENT IS REQUIRED FOR THE SAFETY OF THE OTHER ANIMALS BOARDING. ANY TREATMENTS ADMINISTERED DURING YOUR PETS STAY WILL HAVE ASSOCIATED FEES, WHICH I AM RESPONSIBLE FOR.

Initial: *

Initial for CONTAGIOUS TREATMENT AUTHORIZATION

IF ANY EMERGENCY/LIFE THREATENING MEDICAL PROBLEMS ARE FOUND WHILE BOARDING (RESUSCITATION), I GRANT PERMISSION FOR DOCTORS TO: *

Initial: *

Initial for EMERGENCY TREATMENT SELECTION

IF ANYTHING NON-EMERGENCY/NON-LIFE THREATENING MEDICAL PROBLEMS ARE FOUND WHILE BOARDING, I GRANT PERMISSION FOR DOCTORS TO: *

Initial: *

Initial for NON-EMERGENCY TREATMENT SELECTION

Amount pre authorized : *

I acknowledge that if I am unable to be reached the amount authorized may be used to treat my pet.

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. *

Initial for PROPERTY RELEASE

My belongings I am leaving with my pet are:

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 the following: Rabies, Bordetella (within 6 months), Distemper/Adenovirus (hepatitis)/Parvovirus/Parainfluenza combination (often listed as DHPP or DA2PP), and Leptospirosis (within 12 months), as well as proof of a negative intestinal parasite screen (IPS) in the last 12 months.

We require cats to be vaccinated by a veterinarian for Rabies, Rhinovirus, Calicivirus, Panleukopenia, and having a negative fecal sample within the past 12 months.

It is highly recommended that all vaccinations be up to date at least 7 days prior to boarding.

IF YOUR PET IS DUE DURING ITS STAY FOR ANY OF THE ABOVE WELLNESS SERVICES, AND 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.

Signature *

Clear

Date *

Date

Please verify that you are human *