Please print and bring with you for $5 off of your pet's visit at our boarding facility.

Client Name(s): __________________________

Address: _____________________________

_____________________________________

Home Phone(s): __________________________

Cell Phone(s): ____________________________

Work Phone(s): __________________________

Patient Name: ___________________________

Breed: _________________________________

Species:________________________________

Sex: ___________________________________

Color:__________________________________

Markings: ______________________________

Birthdate: ______________________________

Emergency Number for this visit: ____________________________________

Type of Food:  __________________

Feeding Directions:________________________

Is your pet on Heartworm Preventative?   yes    no 

If yes, what type?________

Is your pet on Flea and/or Tick Preventative?  yes    no 

If yes, what type? _________

Would you like your pet to have a bath?  yes     no 

If yes, special shampoo? _________

Does your pet have any permanent disabilities?  yes   no  

If yes, what type?___________

Is your pet on any chronic medications? ______________________________________

Please list the names, dosages, & directions of any medications your pet will require:
Medication Name            Medication Dosage        Medication Instructions

_______________          _________________      _____________________       
_______________          _________________      _____________________            
_______________          _________________      _____________________           
_______________          _________________      _____________________       

Does your pet like other animals?            yes   no     If no, what type?

Does your pet chew and/or destroy bedding?        yes   no

Would you like for us to text updates regarding  your pet to your cell phone?  yes    no

Phone Number: _________________________

Alternate (permanent) emergency numbers and who can pick up your pet for you:
 

REQUIREMENTS FOR BOARDING

1.  All animals must be current on all required vaccinations. For dogs, these vaccines are Dispemper/Parvo combination, rabies and bordetella and for cats, required vaccines are upper respiratory combination and rabies.
2.   All animals must be free of external parasites (ex. ticks, fleas, etc.), or they will be treated at owner's expense.
3.   Southwest Virginia Veterinary Services has permission to do whatever is necessary should an emergency arise.
4.   If a tranquilizer is necessary for treatment or handling, Southwest Virginia Veterinary Services has my permission to administer such medication.
5.    Your pet must be picked up during normal office hours, unless prior arrangements have been made.
6.  If I neglect to pick up  my pet within 5 days of scheduled departure and have not contacted SVVS then they will assume that  my pet is abandoned.  Southwest Virginia Veterinary Services is then authorized to dispose of my pet as they see fit. I understand that abandonment of my pet does not release me from my obligation to pay the bill.
7.  I understand that payment is expected when  my pet is discharged, unless prior arrangements are made.
8.  If my pet should become injured or ill, refuse food, soil itself or die while boarding, I will not hold  Southwest Virginia Veterinary Services, the doctors or staff responsible or liable in the absence of gross negligence. 

I have read the boarding requirements and understand the hospital's policies.
 
Signature: _________________________________________