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CANINE BOARDING ADMISSION FORM |
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| Owner's Name |
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Date |
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| Pet's Name
___________________________
Breed _______________ Age _____
Sex _____ Color ________________ |
| Responsible
agent/person to be reached in an emergency: |
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Name |
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| Relationship to Owner
________________ |
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Phone Number(s): |
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( ) |
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Camp Cosbie (additional charge)
___ Regular Boarding |
Sharing with
________________________________ |
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YES |
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NO |
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Is this pet on heartworm preventive? |
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Has this pet been checked for
intestinal parasites in the last 6 months? |
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Any vomiting, coughing, sneezing or
diarrhea? |
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Is this pet allergic to any
drugs? If so, please list:
_____________________________________________ |
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Has this pet had any illness or
injury in the past 30 days? |
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Is this pet currently on any
medication? If so, please list: _______________________________________ |
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any type of medication is to be administered while boarding, there will be an
additional charge for this service. |
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| Pick Up
Date: |
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___ A.M. ___ P.M. |
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Please notify us if your return
plans change. |
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| MEDICAL
SERVICES REQUESTED AT ADDITIONAL CHARGE: |
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Physical
Exam / Specificy Problem:
______________________________________________________________ |
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Dental Prophy |
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Update Annual Vaccinations and Test
As Needed |
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Other:
______________________________________________________________________________________ |
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OWNER RELEASE |
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understand you CANNOT guarantee the health of my pet. I
understand and will
not hold the
clinic responsible for |
| conditions
that are unavoidable in boarding kennels, such as but not limited to weight loss, hair loss, upper
respiratory |
| infections,
bronchitis, and diarrhea. I
understand ALL pets admitted to
this facility must be protected against communic- |
| able
contagious diseases and must be
free of internal
and external parasites. I understand ALL pets that
are |
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| boarding
will receive an oral flea treatment called
"Capstar". This oral flea treatment does not affect any medication |
| your pet
may be taking now. We give this to
ALL boarders to ensure we maintain a flea free facility. |
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There is
a one time
$14.00 charge for
the Capstar treatment
per boarding visit. |
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understand that in the event of my pet's illness, the staff will immediately
attempt to contact me or my agent to discuss |
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problem and treatment options, but may not be able to contact me immediately
and is therefore authorized to initiate |
| appropriate
treatment in a life threatening situation until me or my agent can be
reached. |
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| If any problem is observed or develops: |
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Please treat my pet as required, you
need not call me. |
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Perform
only emergency and supportive care.
Notify me for permission to begin any other treatment. |
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Do
NOT perform any diagnostics and/or treatment until I am notified and consent
for you to evaluate and treat |
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as recommended. |
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| Signature:
Owner / Agent |
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Date |
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CBAF040812 |
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