Canine BBN Travel Sheet

Pets Name*

Pets Age*

Weight*

in pounds

Color*

Breed*

Gender*

Owners Name*

Owners Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Owners Phone Number*

Please enter a valid phone number.

Owners Email*

example@example.com

Emergency Contact Name*

Emergency Contact Phone Number*

Please enter a valid phone number.

What date is your pet scheduled for bathing with us?*

Date

When my pet is finished with their visit please:*

Call meText me

Would you like your pet to have deluxe daycare during their visit? (Deluxe Daycare is group play with other dogs, $24.50 for 1/2 day and $44 for full day)

Full Day1/2 Day

In the past 14 days has your pet had any of the following? Select all that apply*

In the past 14 days has your pet visited any of the following?*

Boarding FacilityDoggie DaycareDog ParkNone

If you answered yes to either of the above questions please explain

Is your pet on any medications?*

YesNo

Name of medication, dose, last given (date and time), next dose due

Do you need any refills? If so, please list medication and quantity needed

If you would like us to feed your pet during their visit, what would you like us to feed?

How much would you like us to feed your pet?

How often would you like us to feed your pet?

Special Instructions for feeding

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:*

In the event that your pet needs life saving treatment, please provide a dollar amount that you authorize (if we are unable to reach you).*

Any belongings brought during your pets visit?

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.

Please initial that you have read the above disclosures

CANINE BBN TRAVEL SHEET