Client      _________________________________________________

Pet's Name____________________ Species _____________________    Breed   __________________

Sex__________________________    Age   ______________ mo/yrs       Color_____________________

Telephone Number You Can Be Reached At:          (_____)____________________

Person to Contact in Case of Emergency:

Name: __________________________________         (__ ___)____________________

Arrival Date:  ____________________   Return Date: __________________________           

Bath ____________         Grooming ________________

Diet: ___________________________________________________________________________________

Medications: ___________________________________________________________________________

Special Concerns/Care Instructions:  _______________________________________________________________________________________

Additional Services Requested while Boarding: (Circle Requests)

Tracheobronchitis (Kennel Cough) Vaccine                Annual Vaccines                    Heartworm Test 

Fecal (Intestinal Parasite Exam)                                  Blood work: _______________________________

Surgery / Dental / Anesthesia (download additional surgery consent form)

I hereby consent and authorize Ocala Veterinary Hospital to receive and board my animal(s). I understand the hospital will use all reasonable precautions for the safekeeping of the described animals(s), but the hospital will not be held responsible in any manner whatsoever on account of medical situations that may arise, as it is thoroughly understood that I assume all risks.

I also authorize the hospital to treat any necessary medical conditions that may require treatment prior to my return.  The hospital will make all reasonable attempts to contact the owner or emergency contact person as necessary.  I understand that any  emergency situations will be managed first prior to contact.  Additionally in order to controls fleas in the boarding facility , I understand that a bath and the application of flea control may be required at the owner’s expense.

I further understand it is hospital policy that all annual vaccinations be up to date at the time of boarding. Furthermore, the hospital requires all boarding canines(s) receive an intranasal vaccination to help prevent the incidence and spread of kennel cough. These vaccination requirements reduce the risk to hospital employees and improve the general health condition of the boarding facilities.

After 3 days from written notice mailed to the address on file in the medical record, requesting removal of the animal from the hospital, it will be considered abandoned and may be disposed of, or destroyed as the hospital deems best, and it is understood that such actions do not relieve me from paying all costs of services and the use of the hospital, including the cost of keeping. Balances due are to be paid when the pet checks out.

I have read and understand this authorization and consent.

________________________    ________________    ______________

Owner or Authorizing Agent                   Phone #                             Date