Animal and Pet Veterinary Health Care by lPowell Animal Hospital / Boarding Release Form

Form - Boarding Release

Name (required)
First Name (required)	Last Name (required)

Address (required)
Street Address (required)


City (required)	State/Province (required)	Zip/Postal Code (required)
,

Phone (required)
Phone Type	Phone Number (required)

Phone
Phone Type	Phone Number

E-Mail Address (required) :

Pet's Name(s) (required)

Emergency Number Where Someone Can Be Reached (required)

What dates will your pet be staying? (mm/dd/yyyy)

If your pet is staying more than 3 nights, would you like a half-price bath before pick-up?
Yes.
No.

If your pet is staying more than 6 nights, he/she will be bathed for free prior to departure.

Would you like your pet to have a supervised play time in our fenced in yard for $6.50 per session?
Yes - 2 sessions per day.
Yes - 1 session per day.
No.

Are there any additional services that you request for your pet while boarding?

Please list any abnormalities that your pet has shown recently (i.e. coughing, sneezing, vomiting) (required)

Does your pet have any special needs that need to be taken care of while boarding? (required)

Please list any medications that your pet is taking and any instructions for administration: (required)

Please list any food or belongings that you intent to leave with your pet: (required)

Authorization:
In case of illness or injury, I do hereby give my consent for the doctors of Powell Animal Hospital to treat, prescribe for, or operate upon my pet(s) while they are being boarded at Powell Animal Hospital. They are to use all reasonable precautions against illness, injury, or escape of my pet(s), but they will not be held liable or responsible in any manner whatsoever, under any circumstances, on account of the care, treatment, or safe-keeping of my pet(s), as it is thoroughly understool that I assume all risks. Should the circumstance arise that my pet(s) remain unclaimed after the date which I have state as the pick-up date, I understand that written notice be mailed to the address above. Seven days after such written notice, the pet(s) will be considered abandoned and will become the property of Powell Animal Hospital to be disposed of as we deem best. It is further understood that such action will not relieve me from paying all costs of your service and the use of your hospital, including the cost of the boarding service.

I have read the above and - (required)
I agree.
I disagree.

The verification code below ensures the form is not submitted by a computer

Verification Code :

Enter the code you see in the graphic below in this box.
Your post will not be allowed if you do not type this in correctly.