Countryside - Boarding Agreement Form

1
Pet Name* This field is required.
2
Owners Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Scheduled Drop-off Date for Boarding* This field is required.
Date
Month
Day
Year
5
Scheduled Pick-up Date for Boarding* This field is required.
Date
Month
Day
Year
6
The Doctors and staff at Countryside Veterinary Hospital are pleased to offer your pet a safe and comfortable facility to stay at during your time away from home.
7
Food* This field is required.
Please Select
Please Select
Yes
No
Did you bring your own food
8
Times Fed Per day* This field is required.
Once
Twice
Free Feed
9
When is your pet normally fed* This field is required.
Morning
Afternoon
Both
10
Notes (Type/Amounts)* This field is required.
11
Medications to be given while boarding?* This field is required.
YESNO
12
If yes please add each medication with instruction on when and how much to give. Also let us know when the last time you will have administered the medication prior to dropping off for boarding.* This field is required.
Drug
Amount
Frequency
Last Given (Date, AM or PM)
1.
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
2.
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
3.
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
4.
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
1.
2.
3.
4.
Drug
Row 0, Column 0
Amount
Row 0, Column 1
Frequency
Row 0, Column 2
Last Given (Date, AM or PM)
Row 0, Column 3
Drug
Row 1, Column 0
Amount
Row 1, Column 1
Frequency
Row 1, Column 2
Last Given (Date, AM or PM)
Row 1, Column 3
Drug
Row 2, Column 0
Amount
Row 2, Column 1
Frequency
Row 2, Column 2
Last Given (Date, AM or PM)
Row 2, Column 3
Drug
Row 3, Column 0
Amount
Row 3, Column 1
Frequency
Row 3, Column 2
Last Given (Date, AM or PM)
Row 3, Column 3
1 of 4
13
Would you like for your pet to have a bath before going home? There is an additional fee of $19.72 for this service.* This field is required.
YESNO
14
Would you like us to give your pet a flea/tick treatment?* This field is required.
Yes, 1 mo Flea/Tick Preventative ($31.64)
Yes, 3 mo Flea/Tick Preventative ($77.69 - 83.07)
No
Other
15
Pets boarding together: My pets may board together and I release Countryside Veterinary Hospital of any liability if my pet fights or becomes injured by each other and will pay all medical bills pertaining to treatment of injuries. *
16
Doggie Daycare: I would like for my pet to participate in Doggie Daycare.* This field is required.If your pet has never participated in our Daycare program here at Countryside, they will undergo an evaluation and additional paperwork (also on our website) must be submitted prior.
YESNO
17
If yes, please let us know if you want all day or half day of playtime, and how many days of the week you would like them to participate. Daycare is only available Monday - Friday.* This field is required.
Please Select
Please Select
All Day playtime
Half Day playtime
All Day / Half Day
Monday
Tuesday
Wednesday
Thursday
Friday
Please select what days of the week (you may select more than one day)
18
Requirements for boarding : All pets staying at Countryside must be up to date on Rabies. Dogs must also be up to date on Distemper/Parvo, and Bordetella and Cats must be up to date on their FVRCP. I understand that my pet will be given a Capstar ($6.55) that kills fleas for 24 hours upon arrival at Countryside. If live ticks are found on my pet a Flea/Tick Treatment will be applied to my pet at my expense.

Consent for Boarding: I expect the hospital to use reasonable precautions to ensure my pet’s safety. If my animal should injure his/herself, escape, fail to eat, become ill, or die, I will not hold Countryside Veterinary Hospital and/or its employee’s responsible. As owner (or agent for the owner) of the pet described above, I authorize Countryside Veterinary Hospital to perform any treatment necessary to treat or maintain my pet’s health and well-being if an issue should arise.
19
As owner (or agent of the owner) for the pet described above, agree to the statements made above, and agree to pay in full the cost of boarding and any procedures done when the pet is picked up.* This field is required.
20
Please list any procedures / treatments / surgeries you would like performed on your pet* This field is required.
21
We do NOT recommend bringing your pet’s personal belongings such as beds, blankets, toys and bowls. If you do choose to bring items please provide a detailed description of the item to help ensure that they make it back home. When items go into the laundry or sink for cleaning it is hard to keep track of items. * This field is required.
22
Date* This field is required.
Date
Year
Month
Day
23
Emergency Contact Info for the duration of your pets stay* This field is required.
Area Code
Phone Number
24
Owner or Agent Signature * This field is required.
Clear
25
Hours for Boarding Drop Off and Pick-up

Monday-Friday 7:00am - 5:30pm

Saturday 8:00am - 12:45pm

Tuesday-closed from 12:00am - 2:00pm for staff training

Sunday - Closed (No pick-up or drop-off)
Should be Empty: