Pets Name
*
Owners Name
*
Email
*
example@example.com
Emergency Contact Phone Number #1
Emergency Contact Phone Number #2
Date of Admission
*
Pick Up Date AND Time
*
Boarding Location
*
Luxury (8x8 private room)-$57 per night
Upscale (4x6 boarding run)-$35 per night
Cat Condo-$35 per night
Please Feed My Pet The Following
*
Pet's Own Food
Clinic's Food
Type of Food (if pet's own)
Feeding Frequency
*
Once (morning)
Twice Daily
Once (Evening)
Free Feed
Would You Like a Bath (Baths will be ready for pickup at 12pm)
*
Yes
No
If Your Pet is on Any Medications, Please Note the Medication and the dosing instructions below
*
Medication Type, Frequency and Last Given
All pets boarding must be current on vaccinations. Written proof of vaccinations or verification with the pet's veterinarian must be provided before boarding the pet(s).If parasites are found on the pet during the stay, they will be treated as the doctors of CCVC determine, and the cost of the treatments will be added to the total bill.If the pet must be separated from the general population and put in quarantine, added charges for quarantine procedures will be added to the total bill.If the pet is found to be aggressive and dangerous to the staff or other animals, all additional charges will be added to the total bill.You may request your pet have a bath before discharge. Additional fees apply. However, if the pet's health or temperament makes it hazardous to the staff or the pet, the pet will not be bathed.All reasonable precautions will be used to prevent injury and escape of the pet. CCVC is not responsible for the actions of the pet that may cause injury and escape.
List of personal items left with the pet. (Please include color, size, ect.
*
If the pet is to be picked up by someone other than the owner, arrangements must be made with the veterinary clinic regarding the bill. Agent:
Please confirm:
*
I understand that there is no pick up or drop off of pets on Saturdays, Sundays, or other days that the clinic is closed for business, including holidays.
Vaccination & Exam Due Dates (Office Use)
**MUST be current on all vaccines before boarding**
DOGS
DHPP
Bordetella
Rabies
Influenza
CATS
FVRCP
Rabies
Leukemia (optional for boarding)
FERRETS
Distemper
Rabies
List of Personal Items with Pet (include color, etc)
Type a question
*
***PET OWNER ASSUMES RESPONSIBILITY FOR LOSS OF AND/OR DAMAGE TO ALL ITEMS (leashes, toys, towels, etc.) LEFT WITH THEIR PET. The pet owner is also financially responsible for any damages incurred by their pet to Country Club Veterinary Clinic and its property. Country Club Veterinary Clinic will be reimbursed by the pet owner for any damages/repairs necessary. *** The undersigned hereby warrants that they are the owner or authorized agent for the pet listed in this record and does consent and authorize Country Club Veterinary Clinic (CCVC) to care for and treat said pet. If an emergency situation arises, I authorize services, including the use of anesthesia if necessary, to treat my pet until such time as I can be contacted. I understand that every reasonable effort will be made to contact me as soon as possible if an emergency or unanticipated situation arises with my pet. If I am unable to be reached, I authorize the veterinarians to proceed with treatment as deemed necessary for the well-being of my pet. I understand I will be responsible for all charges incurred at checkout. If I have requested that medical, surgical, dental, or other services be performed for my pet while he/she is residing in the boarding kennel, I consent to and authorize the CCVC to perform diagnostic, therapeutic, anesthetic, emergency, and surgical procedures as are necessary and advisable for the treatment and maintenance of my pet’s health and well- being. I understand that with any procedure or treatment that there are risks that may not be predictable, including death, and I accept these risks. While I expect all procedures to be performed to the best of the abilities of the staff, I acknowledge that no guarantee or warranty regarding the outcome or results of any treatment has been given. I acknowledge that hair may be shaved or clipped as necessary to facilitate treatment. I expect that reasonable precautions will be used to ensure my pet’s safety and well-being while in CCVC’s care, and I agree to pay in full for all services provided at the time of discharge. I understand that if an unanticipated need for additional procedures or services (e.g. extractions of teeth, biopsies of abnormal tissues, etc.) occurs, a reasonable effort will be made to contact me using the contact information provided above. I understand that if I cannot be contacted, that non-emergency procedures or services will not be performed, at that this may mean that my pet may need to have another procedure at a future date at my expense. The undersigned understands that some pets become stressed or anxious while in a kennel environment, CCVC will treat all boarded pets for stress related issues including, but not limited to, diarrhea, vomiting, drooling, excessive panting, pacing, inappetence as deemed necessary for the health and safety of the pet. Medications will be administered as needed for stress and/or anxiety and will be at the expense of the owner. Any pet(s) not picked up within 10 days after owner scheduled pick-up date will become the property of Country Club Veterinary Clinic and WILL BE SURRENDERED to Calcasieu Parish Animal Services. All accrued charges will apply.
Signature
Date
-
Month
-
Day
Year
Date
Submit Form
Should be Empty: