Boarding Admission Form Check-In Date*Check-Out Date*Pick Up Time*Client InformationClient Name First Last Home PhoneCell PhoneEmergency PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Pet InformationPet's NameSpeciesAgeBreedColorWeightPlease help assist us in your pet’s admitting physical exam:Is your pet on heartworm or flea preventative?YesNoIf yes, what brand of heartworm prevention?When is the next treatment due?If yes, what brand of flea prevention?When is the next treatment due?Any vomiting, coughing, sneezing, or diarrhea?Select all that apply Vomiting Coughing Sneezing Diarrhea NONEHas your pet had any illness or injury in the past 30 days?YesNoIf yes, please listEars/skin acceptable, no fleas/ticks being seen?YesNoIf yes, please listAny pet behavioral issues? (climbing, fears, aggression, other)YesNoIf yes, please listWould you like your pet bathed while at our facility?*A complimentary bath is provided for any boarder staying more than seven (7) consecutive nights otherwise, a bath is available at a fee according to weight. *Pet’s being bathed will need to be picked up in the afternoonYesNoIf fleas are detected, topical or systemic flea medication must be applied for a feeI understandIf needed, select a preference:Dogs: Frontline Gold | Nexgard | Capstar | No Preference Cats: Frontline Gold | Revolution | Capstar | No PreferenceFeeding InstructionsDid you bring your pet’s own food?YesNoIf yes, please listHow much do you feed?How Often?Was your pet already fed today?YesNoIf yes, what time?Did you bring any special treats?YesNoHow often are they given?MedicationsIs your pet on any medication?YesNoIf yes, pease listNameDirectionsLast Given (click "+" symbol to add moreOther BelongingsDid you bring any bedding, towels, toys, other?YesNoIf yes, please listOwner's ReleaseYou are to use all reasonable precautions against injury, escape, or death of my pet. The clinic and staff will NOT be held liable for any problems that develop provided reasonable care and precautions are followed. I understand ANY problem that develops with my pet while I’m absent will be treated as deemed best by the staff veterinarians and I ASSUME FULL RESPONSIBILITY for the treatment expense involved. If I neglect to pick up my pet while within 5 days of the listed pick-up date and do not notify you within that time frame, you may assume the pet is abandoned and are hereby authorized to relinquish the pet as you deem best and/or necessary.If any critical or life-threatening illness due to any new or on-going illness become manifest during my pet’s period of boarding:* Please perform only emergency and supportive care. Notify me or my agent for permission for any other treatment. I understand that Safe Haven Veterinary Hospital will be diligent in their efforts to contact me. If contact cannot be made, Safe Haven Veterinary Hospital will provide care–including humane euthanasia -as deemed in the best interest of my pet. Please provide any and all necessary care as deemed appropriate prior to contacting meIn Case of an emergency where I am not available, please call:Emergency Contact NameEmergency Contact NumberOwner's Signature*Date* Date Format: MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
