Last name:___________________ First name(s): _____________________
Home phone: _________________ Cell phone(s): _______________________
Emergency Contact(s): ___________________________________________
Drop-off date: ____________ Pick-up date and time: ____________________
Pet name: _______________
Sex: _________ Altered? ___
Date of Birth: ____________
Date of last exam: ________
Date of last vaccinations:
FELV________ Rabies ______
- With my pet, I also dropped off (circle): Food Medications Bed Bowl(s) Toy(s) Leash Other: _________
- Feeding instructions: Please list type of food, quantity, and frequency:
- Medications: Please list name, dose, and frequency:
I understand that:
- Though every attempt is made to return belongings in their original condition, I assume full responsibility for any lost or damaged personal belongings (including leashes, collars, bedding, toys, etc).
- I must provide proof of a current physical exam (within one year) and vaccination status. Special exceptions may be made only by doctor approval.
- If my pet has fleas, flea protection will be used so as not to infest other patients in the clinic. The cost will not exceed $23.00.
- If an emergency occurs, and I cannot be reached (or my emergency contact cannot be reached), I authorize the doctor to do what s/he deems necessary for the care of my pet.
- My pet will be walked at least 3 times daily. If s/he becomes soiled, s/he will be cleaned. Any additional bathing will be at my expense.
- All charges are due at time of pick up.
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