Boarding Release Form Cheyenne

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Please note: all pets must be current on vaccinations in order to board at Cheyenne West Animal Hospital.

Is your pet current on vaccinations?*

YesNo

Do we have permission to vaccinate your pet?*

YesNo

Please note: All pets must have had a negative fecal test in the past year.

Do we have your permission to test a fecal sample?*

YesNo

Did you bring any personal items for your pet?*

YesNo

If yes, please list personal items:

Which food will your pet be eating during their stay?*

My own food brought from homeFood provided by Cheyenne West Animal Hospital

If bringing food, what brand of food are you bringing?

How much and how often would you like us to feed your pet?*

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone*

Please enter a valid phone number.

Pet's Name*

Pet's Age*

Pet's Gender*

Pet's Breed*

Pet's Color of Coat*

Please list any medical concerns with your pet:

Is your pet currently on medications or supplements (either prescription or over-the-counter)?*

YesNo

If yes, list medication, strength, daily dosage amount, and last time given:

PLEASE NOTE: ALL MEDICATIONS AND SUPPLEMENTS NEED TO BE IN THEIR ORIGINAL CONTAINER. MEDICATIONS NOT IN THEIR ORIGINAL CONTAINER WILL NOT BE ACCEPTED.

We do offer baths to dogs while they are here. A bath is complementary after four nights of boarding. We apologize, but we cannot accomodate complementary baths around holiday boarding times.

Would you like us to give your pet a bath while they are here?*

YesNo

In case of emergency, do we have your permission to treat?*

YesNo

If you refuse treatment, this may lead to serious health problems, or even death, in some cases.

Please call our office if you cannot pick-up your pet on the scheduled pick-up date. Space is limited and we cannot always accomodate extended stays. Failure to call will result in an additional $6.00 per pet per night charge. I further understand that all boarding fees are per pet, not per cage.

I am the owner or agent for the pet(s) described above and I have the authority to execute this consent. I fully understand that I assume all risks while boarding my pet(s). A hospital staff member has explained to me that the hospital is not staffed with personnel overnight. The hospital and staff will not be held liable for any problems that develop provided they have taken all reasonable care and precaution against injury, escape, or death of my pet(s). This is to certify that I have been informed on and agree to the policies regarding boarding including vaccinations and all associated costs as the hospital staff has explained them to me. I am the owner or agent for the owner and I have the authority to exercise this consent.

Comments or requests for the doctors:

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