Owner's name: _______________________________________________
Address: ___________________________________________________
Phone number_______________________________________________
Pet's name: ___________________ Dog or Cat _____________________
Breed ____________ DOB ___________ Coloring __________________
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Drop off
date: _______________ Pick up date: _____________________
Belongings brought with pet _____________________________________
If my pet becomes
ill during its stay at Companion Animal Care Center, I understand
that the veterinarian and/or staff will try to reach me at emergency
numbers that I have given. I
n the event that I cannot be reached, and my pet needs specific treatment to insure the safety
of my pet, I allow
them to: (Choose one)
______ Perform whatever services/procedures
the doctor deems necessary for the best care
of my pet until I can be reached. This includes non-elective treatment
and/or procedures and any diagnostic tests.
______ I authorize up to $_______ in medical care until I can be reached.
______ Please keep trying the
emergency phone numbers given before you perfom any procedures.
I authorize
the veterinarian and staff of Companion Animal Care Center to board my pet
during the period specified above.
I
understand that my pet must be currently vaccinated and free of external
and internal parasites.
Additional procedures I would like perfomed on my pet during its stay include:
microchip-> ( ) nail trim-> ( ) anal sac expression-> ( )
other ______________________________________________________
I would _____
would not _____ like a bath for my pet on the day I pick up my pet.
I understand
that Companion Animal Care Center is only staffed during office hours therefore
boarded
pets are NOT observed
24 hours a day.
________________________________________
_______________
signature of owner
date
Where I can be reached while away:___________________________________________________________
Person to call
if I can't be reached:
_________________________________ _______________________
name
number
