"*" indicates required fields Thank you for entrusting your pet’s care to us today. The following information will be used to help our veterinary team accurately complete your pet’s medical history for their visit. We ask that you provide this information 24 hours in advance. Owner Name* First Last Phone*Alternate Phone NumberEmergency Phone Number*Email* Pet's Name* Species Dog / Canine Cat / Feline Intake InfoCheck In Date MM slash DD slash YYYY Check Out Date MM slash DD slash YYYY FEEDING INSTRUCTIONS (ADDITIONAL CHARGES WILL APPLY FOR CANNED CLINIC FOOD):*Own FoodClinic DryClinic CannedOTHER FEEDING INSTRUCTIONS:LIST ANY MEDICATIONS, INCLUDING DIRECTIONS AND WHEN TO STARTPlease note that there is an automatic $15.00 administration of medications fee.Do you need a refill of any medications while your pet is boarding? YES NO If yes, please explainWould you like your pet to have a bath prior to check out? Yes No *Disclaimer: Please do not leave any leashes or collars at the clinic*DOCTOR/TECHNICIAN EXAMSIf your pet is being examined by the doctor during this stay, please briefly explain the reason for the exam (ie vaccine boosters, recheck, new illness)EXAM AUTHORIZATIONWhile every attempt will be made to contact you after the exam, in case we are unable to reach you, do you authorize the veterinarian to begin treatment during your pets stay? Yes No In the event of an unforeseen emergency and Memorial Veterinary Clinic is unable to contact me, should my pet experience a cardiac, respiratory or other life-threatening emergency that requires resuscitative or other urgent care measures, such as cardiopulmonary resuscitation (CPR), positive pressure ventilation, emergency drugs, or other similar measures, I request that the veterinarians and/or trained staff at Memorial Veterinary Clinic pursue such medical care as indicated below.* Resuscitate (R): I authorize emergency treatment if the situation arises (including cardio pulmonary resuscitation (CPR) and other life-saving treatments) and understand this may result in additional charges and I agree to pay for these emergency and life-stabilizing treatments even if they exceed any estimate I may have been provided. Do Not Resuscitate (DNR): I do NOT authorize emergency treatment if the situation arises (including cardio pulmonary resuscitation (CPR) and other life-saving treatments) and prefer to be contacted before any additional treatment is performed. Boarding AgreementI certify that I own said the aforementioned pet and authorize Memorial Veterinary Clinic staff to board said animal and perform the boarding and or treatments I have requested. InitialDuring this time, Memorial Veterinary Clinic may administer vaccinations, medications, test procedures, anesthetics, or treatments deemed necessary for the health, safety, and well-being of said animal while under your care and supervision. I understand that every effort will be made to contact me prior to the performance of these procedures. InitialIf said animal should injure itself in an escape attempt, refuse food, soil itself, become ill, or die while in the hospital, I will hold Memorial Veterinary Clinic and staff free of all responsibility and/or liability in the absence of gross negligence. InitialI understand that all animals hospitalized for boarding and medical procedures are required to be treated for external parasites with Capstar, including if they are current on a form of flea preventative. This is not only for the comfort and safety of my pet but also for other pets in the hospital. InitialI further understand that all canines staying within the facility must be currently vaccinated against rabies, bordetella, influenza and distemper parvo. I further understand that all felines staying within the facility must be currently vaccinated against rabies and feline distemper parvo. I authorize the Memorial Veterinary Clinic to perform any required services at my expense as deemed necessary by the veterinarian. InitialI further realize that I am responsible for payment of all above-mentioned procedures and treatment in full at the time the animal is discharged. If I neglect to pick up the animal within five (5) days of written notice that it is ready for release and mailed to the above address, you may assume that the animal has been abandoned. You are then authorized to dispose of it as you see fit. Abandonment, however, does not release me of my obligation for payment of said bill. InitialI further agree that in the case of nonpayment, to pay a finance charge of 1.5 percent per month (18 percent per annum), a $2.00 per month billing charge, and any and all collection or attorneys’ fees incurred by Memorial Veterinary Clinic relating to this matter. InitialI understand that my pet(s) will be bathed at my expense prior to release in the event he soils his self. InitialIn the event of weather evacuation, we must have an alternative person of contact who is able to pick up your pet(s) within an hour of a mandatory evacuation issuance. We will not have staff on premises to care for your pet(s) during a weather evacuation. InitialSignature*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.