Sunday, May 20, 2012
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American Animal Hospital Association

BOARDING AGREEMENT RELEASE FORM
If you prefer to download our PDF form instead of using our online form, please click the link below and fax the completed form to 804-794-3015. Ask about our frequent boarder program!
Boarding Agreement Release Form
 
Your Name:
E-Mail Address:
Pet's Name:
Today's Date: May 20, 2012
Pick-Up Date: (mm/dd/yyyy)
Emergency Telephone:
Alternate Contact Name:  
Alternate Contact Phone Number:
   
Our Policy:
All fees are to be paid at the time services are performed.

In the event of a medical emergency, I authorize Midlothian Animal Clinic to administer treatment and/or perform diagnostic or surgical procedures as Midlothian Animal Clinic deems necessary.  Midlothian Animal Clinic will make every attempt to contact you using the emergency contact number above.  After this, we will use the alternate contact number, then we will attempt to contact you via e-mail.  I accept responsibility for any fees resulting from care and treatment provided by Midlothian Animal Clinic.

I agree to this policy
   
Required Information: Please answer the following questions:
We require all pets boarding with us:
  • to have a current physical exam by a veterinarian within one year for pets under 7, and every 6 months for pets 7 and older (if never seen at MAC, patient must be examined by our doctor)
    Is your pet up to date on his/her exam?  Yes   No
  • to have received veterinarian administered vaccinations within the year. (Distemper, Rabies, Canine Bordetella)
    Is your pet up to date on his/her vaccinations?  Yes   No
  • to be flea free. (If fleas are present, preventative will be applied at an additional charge)
    Is your pet on flea prevention?  Yes   No   Type:
  • if currently on medications to continue medications while boarding.
    Is your pet currently on any medication?  Yes   No   If Yes, List all medications below:
There is an additional fee for dispensing medications:
Medication 1:
Once   Twice   Three times Daily
Special Instructions:
Medication 2:
Once   Twice   Three times Daily
Special Instructions:
Medication 3:
Once   Twice   Three times Daily
Special Instructions:
   
Additional Services Available (extra charges apply):
I would like to have my pet examined while being boarded. Yes   No
I would like to have my pet vaccinated while being boarded. Yes   No
I would like to have my pet bathed prior to pick-up. Yes   No
I would like to have my pet receive another service while being boarded. Yes   No   
Special Instructions:
    
 

14411 Sommerville Court • Midlothian, VA 23113 • 804-794-2099 • Fax 804-794-3015 • info@macvetva.com