Springs Road - Boarding Consent

1
Pet Information
Pet name
Breed
Color
Please Select
Please Select
Male
Female
Male Neutered
Female Spayed
Sex
Age
Weight
2
Client Information
Client Name
Cell Phone
Home Phone
Email
3
Boarding Check In/Check Out
Boarding Check In
Checked In By
Boarding Check Out
Checked Out By
4
In order to protect my pet and others, external parasites such as fleas or ticks will be treated on entry. I understand that my pet must also be up to date on vaccinations and have an in-date fecal exam. My pet was vaccinated at: Text Here
5
Date of Canine Vaccines
Rabies
DHLPP
Bordetella
Fecal Exam
Flea/Tick prevention and Date given
Heartworm prevention and date given
6
Diet, amount and frequency fed
Other medication(s), dose and frequency
7
Date of Feline Vaccines
Rabies
FVRCP
FeLV
Fecal Exam
Flea/Tick prevention and Date given
Heartworm prevention and date given
8
Diet, amount and frequency fed
Other medication(s), dose and frequency
9
My pet can have a blanket
YESNO
10
Would you like your pet to be allowed to run off leash in the yard?
Yes, I want my pet to run in the yard
No, I would prefer my pet to beleash walked only
11
Please list and describe all toys and possessions you are leaving with your pet.
12
If your pet is staying for more than one night, he/she will likely get soiled, and so we recommend a bath.
I want my pet bathed.
I want my pet's nails trimmed before going home.
13
I would also like for my pet to have the following services performed while boarding.
14
If I cannot be reached, please contact the following person First Name Last Name at phone number Phone Number
15
I have verified that my contact information is complete and accurate. I understand that the employees of SRAH, PLLC will attempt to contact me in the case of an emergency. However, if I cannot be reached, I understand that my pet will be treated at the discretion of the veterinarian on duty. By signing this document, I give permission to SRAH, PLLC and its employees to treat my pet while he/she is boarding at the hospital.

I am the owner (or authorized agent of the owner) of the animal described above, and have the authority to execute this consent. The fees associated with these services have been explained to me, and I agree to pay such fees at the time these services are completed.
16
Signature* This field is required.
Clear
17
Name* This field is required.
18
Phone * This field is required.
19
Date* This field is required.
Date
Year
Month
Day
Should be Empty: