Boarding

Southside Place Animal Hospital

Boarding Check-In

Patient Name

Client Name

Arrival Date

Date

Departure Date

Date

Phone

Email

example@example.com

In the event of unforeseen weather evacuation hurricanes, etc, we will need emergency contact information for someone who will be available to pick up your pets

Name:

Phone Number

Area CodePhone Number

Email

example@example.com

Client Feeding Instructions: Diet Amount and frequency: (For safety and sanitation reasons we will be unable to feed any raw diets while your pet(s) board at the clinic. We will try to accommodate any medical diet concerns such as food trials with an equivalent version of diets we carry at the clinic

Diet

Supplied by ClinicSupplied by Client

Amount and frequency*

(For safety and sanitation reasons we will be unable to feed any raw diets while your pet(s) board at the clinic. We will try to accommodate anymedical diet concerns such as food trials with an equivalent version of diets we carry at the clinic.)

Extended Leash Walks (Monday through Saturday. Dogs only - $6.50/walk)*

NoIf yes, once or twice daily?

Bath the morning of departure?*

YesNo

Would you like a veterinarian to look at your pet today?*

NoYesIf yes, please list concerns.

I acknowledge that Southside Place Animal Hospital is a flea/tick free facility. If live parasites are found on my pet, I understand it will be treated at my expense.

Please enter initials

I acknowledge that my pet is current on all vaccinations required by Southside Place Animal Hospital and that written proof must be provided.

Please enter initials

I acknowledge that my pet must be examined by a veterinarian at Southside Place Animal Hospital within the past year and have a fecal exam performed by either Southside Place Animal Hospital or a licensed veterinarian's office in the past year in order to board at our facility.

Please enter initials

Medication Administration Required?

Name of Medication

Instructions

When to begin meds?

Am or PM

Name of Medication

Instructions

When to begin meds?

Am or PM

Name of Medication

Instructions

When to begin meds?

Am or Pm

Do you need a refill on any medications:*

YesNo

Heartworm Prevention:

6 months12 months

Flea/ Tick Medications:

6 months12 monthsOther

We will attempt to contact you in the event that unexpected medical attention is deemed necessary by the medical staff. If we are unable to contact you, do we have permission to treat:

Minor issues such as ear/skin/diarrhea?

YesNo

Emergency Procedure?

YesNoMax Amount $

Transport to Emergency Facility (if needed)?

YesNo

I accept full responsibility for all charges related to the treatment of my pet.

Owner / Authorized Representative

Date