1 Start 2 Complete OWNER/CLIENT INFORMATION Owner’s Name * Owner’s Phone * Email * Pet’s Name (1) Pet’s Name (2) Pet’s Name (3) Check-in Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Pick-up Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Pick-up Time (Approximate) Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Emergency Contact Emergency Phone SPECIAL INSTRUCTIONS If boarding multiple pets, do you want them to share the same condo? (Cats cannot share small condos) Yes No Would you like your pet to have a bath before going home? Yes No If yes, please explain: If getting bathed, please pick up your pet after 3pm Monday-Saturday. If it is necessary to pick up early Monday morning, the bath will be given Saturday. Please bring any medicated shampoo with you at check-in. If yes, what date? Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2019202020212022 Has your pet had recent bouts of coughing, sneezing, vomiting, diarrhea, lameness, or limping? Yes No Please explain any other concerns about your pet that you would like the Veterinarian to evaluate while your pet is staying with us: Is your pet on any medications? Yes No If yes, please list the drug and dosage, and when the next dose is due: Are you bringing your own food? Yes No If yes, please name the food, how much you feed, and how often you feed each day: Is your pet allergic or sensitive to any food or medication? Yes No If yes, please explain: What is your dog's current flea and tick prevention? When was it last given or applied? Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year201520162017201820192020 What is your dog's current heartworm prevention? When was it last given or applied? Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year201520162017201820192020 Would you like your pet to have an extra walk or playtime while staying with us? ($6.00 per day) Yes No Please list any other special needs or instructions for your pet while staying with us: If your pet is being seen by a doctor, which do you prefer? (Please check one) To be called with the exam results To have a scheduled time to go over the exam at pick-up To have a scheduled appointment the day of check-in Important Notice About Vaccinations and Prevention All guests staying in our facility are required to be up-to-date on vaccines and flea and tick prevention. The requirements are as follows: Dogs: Physical exam, Canine Influenza (H3N8 and H3N2), Bordetella, Distemper, Leptospirosis, Rabies, and Intestinal Parasite Screening Cats: Physical exam, Feline Distemper, Rabies, and Intestinal Parasite Screening • If your pet is not up-to-date, these services will be performed upon arrival, unless waived by a doctor for medical reasons. • It is our policy that all pets (dogs) receive a dose of flea and tick prevention upon arrival, if not current in the past 30 days. Additional Fees/Discounts May Apply We want to ensure the best experience for you and your pet when they board with us and/or receive our bath services. For the well-being of your pet, we want your pet to stay healthy and clean. By signing this document below, you agree to the terms and conditions outlined in this section, "Additional Fees/Discounts May Apply." The following adjustments will apply to dog boarding and dog bath rates: • If boarding for 3 to 6 nights, a bath is MANDATORY prior to departure, but the bath will be discounted 25% from standard rates. • If boarding for 7 nights or more, a bath is MANDATORY prior to departure, but the bath will be complimentary and discounted 100%. • Long-haired pets require extra time and attention to ensure they are fully dry and tangle free. An additional $10.00 "Long HairDrying/Brush Out Fee" will apply to pets who require this extra time and attention. • An additional $5.00 "Boarding - Holiday Fee Per Day" will apply to boarding reservations around a holiday. This charge will apply forthe 3 days PRIOR to the holiday, the day of the holiday, and the 3 days AFTER the holiday, for up to 7 days. Additional fees apply for: • Dog and cat boarding with Special Medications/Diet • Dog and cat boarding with a Medical Condition Personal Property It is our policy not to have blankets, beds, or other personal items with your pet in our boarding facilities unless permission is given by a Veterinarian. By signing this document below, you understand that leaving any belongings, including leashes, collars, blankets, and/or toys, will be at your own risk, and you will not hold Northeast Animal Hospital responsible for any lost or damaged items. Please sign below that you have read, understand, and agree to the above terms and conditions. Please sign your name using your mouse or cursor. Signer Name *
