Client:________________________________
Patient:_______________________________
Today's Date:__________________________
BOARDING AGREEMENT

Date of Pick-Up ________________________ am        pm   (After 3 pm if bath)

                                                            Please circle one

Playtime? (Additional charges)

Yes     No

Date(s):__________________________

Fecal Exam?

Yes     No

A negative fecal within the last 6 months is required for Playtime.

Bath while boarding?

Yes     No

Date to be done: ______

Medication?

Yes     No
(if yes, see below)

There is an additional charge for the administration of medications.

Medication Instructions:

Diet Instructions:

Person(s) to contact in case of emergency who will be able to authorize treatment:
Name: _________________ Phone: __________
Name: _________________ Phone: __________
If no one can be reached, please authorize a dollar amount to be used for emergency care of your pet until someone can be reached. (please circle one or fill in appropriate amount)
$100    $150    $200    $250     Other $________

Pet's Belongings:

Please have the doctor perform an exam to check for the following: (describe problem in detail; an exam fee will be charged plus any diagnostics or medications needed)

Vaccinations; to ensure protection of all pets under our care, we will update any necessary vaccinations (staff member will circle all that apply for your pet)

Dogs          DHPPC(L)          Bordetella          Rabies          Lyme
Cats            FVRCP               Bordetella          Rabies          FeLV

If one of the topical flea preventatives listed on the right has not been applied to your pet within the last 30 days, we will apply a dose on administration (staff member will circle most appropriate):

Advantage
Frontline
Revolution
K9 Advantix (dogs only)

I give my permission for Greens Fork Animal Hospital to perform any and all above mentioned procedures.
Owner's Signature: ______________________________________ Date: _________________
Admitted by: ___________________________________________  In Computer: __________