Fairview Heights Animal Clinic - Boarding Agreement Form

Boarding Agreement
Kennel Hours:

Mon-Sat 8-12 - pick up & drop off
Wed/Fri pm pick up/drop off from 3-6
Sat 3-4, Mon/Tues/Thur 3-5

There is NO overnight staff

All dogs are walked 3x daily
Client Information
Check-In Date*

MonthDayYear
Date
Check-Out Date*

MonthDayYear
Date
What time will you be picking up? *Pets must be picked up by before noon (12pm) to avoid an additional charge.*

Before 12pmAfter 12pm
Owner's Name*

First NameLast Name
Owner's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet Name*
Pet's Gender*

MaleFemale
Pet's Approximate Age*
Species*

CanineFeline
Spayed or Neutered*

YesNo
Breed*
Color*
Emergency Contact
*Must be someone other than yourself and is local. Please take into consideration, this person may be called upon to transport your pet to an emergency facility. We will make every attempt to to reach you first.
Owner initials*
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
Emergency Contact Email*
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.
Emergency Contact Email
example@example.com
Special Instructions

TO BE COMPLETED BY OWNER
Medication #1
Strength
Administration Instructions
Medication #2
Strength
Administration Instructions
Medication #3
Strength
Administration Instructions
*If medications are required and are not provided by the owner, or are provided in an insufficient amont, a prescription refill fee will be added to the boarding bill. Medication administration fees of $7.15 per day, per pet, will be added for those pets requiring medication administration during their stay.
Owner Initials*
Please list any allergies your pet may have
Pet's diet (amount and feeding instructions)*
Will your pet need a physical exam/surgical or dental procedure during boarding?*

YesNo
Are you interested in adding Doggy Day Care with Boarding?*

YesNo
Please call our clinic (618) 398-1530 to learn more about Doggie Daycare services and adding it to your pets stay.
To Be Completed By Kennel Staff:
Admitted By
Admitted Date
Vaccines Verified By
Additional Information
If your pet is to be picked up by someone other than the owner, arrangements regarding the bill must be made in advance with the kennel staff
Name of person authorized to pick up pet*

First NameLast Name
In the event we are unable to contact you if your pet becomes ill or experiences prolonged distress while boarding, it is important that we have your authorization to treat your pet. Please read the following and initial:

Treat my pet as needed. This may include diagnostic tests, treatments and/or surgery. After hours, the medical staff is not on the premises and if it is determined that your pet requires immediate medical attention, we will call your emergency contact for transport. I accept full financial responsibility for all charges related to the treatment of my pets.
Owner's Initials*
Owner's Signature*

Clear
Today's Date*

MonthDayYear
Date
We will make every effort to contact you regarding your pet's condition and treatment therefore it is imperative that emergency contact numbers be up to date. Thank you!
Should be Empty:

Boarding Agreement

Client Information

Emergency Contact

Special Instructions

To Be Completed By Kennel Staff:

Additional Information