Boarding Check-In Form

Client Name *

First NameLast Name

Email

example@example.com

Pet Name*

Breed*

Color*

Age*

Sex*

Spayed/Neutered *

YesNo

Boarding pets will be admitted & discharge by appointment during normal business hours.

Pick-up Date

Hour MinutesAM/PM Option

Will you be picking up your pet*

YesNo

If not, who is authorized to pick up your pet

When written proof of the vaccinations is required by Middletown Animal Clinic boarders will be vaccinated upon admission, if proof is not provided at the time of admittance Initial here

Update

Upload here

Is your pet on a heartworm prevention?*

YesNo

Any vomiting, coughing, sneezing, or diarrhea?*

YesNo

If yes explain

Is your pet allergic to any drugs?*

YesNo

If yes list

Any illness or injury in the last 30 days?*

YesNo

If yes explain

Is your pet currently on any medication? *

YesNo

If yes please list below

	Medication Name	Dosage	Dosage Instruction	Time Last Given
Medication #1
Medication #2
Medication #3

Please list problems (if any) to check or treat while your pet is boarding

Ok to treat my pet

Please call with an estimate before treatment

Please list any additional services you would like for your pet during their boarding stay

Ok to provide additional services

Please call with estimate before services rendered

Items Brought: We furnish all normal food and bedding. We prefer our clients not to leave toys or pet bedding, due to our strict sanitation procedures. We cannot be responsible for any item left with your pet. All collars will be removed and returned to you at the time of admission as we provide your pet with an identification collar during their stay.

Unless otherwise instructed all pets are fed Science Diet dry food while boarding.

Does your pet have a special diet*

YesNo

Special Diet (needs to be brought with your pet)
Amount your pet is to be fed AM PM

Other

All boarders must be free of external parasites (fleas & ticks) when admitted for boarding; or must be treated upon admission.   Initial here

Any boarder that requires emergency or immediate veterinary attention will receive it at our discretion, and at the owner's expense.   Initial here

Should my pet(s) require cardiopulmonary resuscitation (CPR), including cardiac compression, positive pressure respiration, and/or emergency drugs, I request the doctor(s) at Middletown Animal Clinic, Inc. to pursue such care as indicated above until staff members reach me for further directions. Regardless of my pet’s survival, I agree to pay the resuscitation fee in addition to the other fees already identified.
Approve   Disapprove

Be aware that your pet’s diet may have varied while away from home. They may have barked at other animals; or the temperature & humidity may have been slightly different from your home. This can create problems such as sore throats, tonsillitis, and/or diarrhea.

Be aware that your pet could have been in the “incubation period” of some infectious disease when brought to the clinic for boarding. Signs of disease may not develop for several days after exposure to an infectious agent. Even though you assume your pet is healthy, and even though we examine your pet upon admission, it is impossible to detect many problems until your pet starts to show clinical signs. Also, changes in normal routines can result in “stress.” Any form of stress can weaken the immune system allowing some hidden disease it has been incubating to become apparent resulting in a sick pet.

We seek to prevent such problems, but you must understand that these problems can develop. Owners will be charged appropriate fees for all treatment and medication needed for reasons that are not directly under our control.

We treat every boarder entrusted to our care the same as we treat our own pets. Our own personal pet’s board in our kennels when we are out of town just as your pet does. Please inform us if you are not happy with the way your pet was cared for. Your satisfaction and your pet's well being are our primary concern.

Primary name

Phone Number

Secondary name

Phone Number

Other number

Owner Release
You are to use all reasonable precaution against injury, escape, or death of my pet. The hospital and staff will NOT be held liable for any problems that develop provided reasonable care and precautions are followed. I understand that ANY problem that develops with my pet while I am absent will be treated as deemed best by the staff veterinarians and I assume full responsibility for the treatment expense involved. If I neglect to pick up my pet within 5 days of the above date and do not notify the hospital within that time period, you may assume that the pet is abandoned and are hereby authorized to dispose of the pet as you deem best and/or necessary.I agree to pay, in full for services rendered including those deemed necessary for medical or surgical complications or unforeseen circumstances.

Payment will be made by *

Witness

Date

Owner/agent signature

Boarding Check-In Form

Pet Description

Medical History

Please provide emergency contact information