Boarding Registration Form "*" indicates required fields Date* MM slash DD slash YYYY Your Name* First Last Choose Hospital Location*MesaPhoenixClient #Patient Name*Date In* MM slash DD slash YYYY Time In Hours : Minutes AM PM AM/PM Date Out* MM slash DD slash YYYY Time Out Hours : Minutes AM PM AM/PM Vaccine/PreventivesFor the protection of your pet and all pets under our care, the following must be up-to-dateFlea/Tick* Current Needs What product and when it was given?*The hospital can apply an immediately effective product, that lasts for 1 month, at check in, for an additional fee.Bordetella* Current Needs Veterinarian/Hospital That Vaccinated Your Pet:*Do you already have an appointment scheduled to update your pet's vaccines?* Yes No Rabies* Current Needs Veterinarian/Hospital That Vaccinated Your Pet:*Do you already have an appointment scheduled to update your pet's vaccines?* Yes No Dhpp/Fvrcp* Current Needs Veterinarian/Hospital That Vaccinated Your Pet:*Do you already have an appointment scheduled to update your pet's vaccines?* Yes No Emergency Phone Number*I authorize my emergency contact to make medical decisions on my behalf should the need arise?* Yes No Pet Owner Medical ReleaseOne of the advantages of boarding your pet at our Hospital is that veterinary care is readily available should the need arise. As Pet Owner, please select your choice(s) below:* Please perform whatever services and treatments the Doctor deems necessary for the best care of your pet. It is not necessary to contact me prior to these services and/or treatments. I accept full responsibility for additional costs incurred in the medical treatment of my pet. We will call the emergency number listed above regarding my pet’s symptoms, treatment options and give you an estimate of additional costs. In the event that I am unavailable:* I elect minimal treatment for my pet to prevent life-threatening concerns. I understand that minimal treatment can include the need for intravenous fluids, oxygen, and possibly intensive care treatments. I understand and agree that I will be financially responsible for the total amount of all treatment costs for my pet. I decline treatment for my pet without my permission. I understand that if I am unavailable and my pet’s life is threatened, no treatment will be done, and, I hereby release Family VetCare and its representatives of any and all responsibility and/or liability. Does your pet have any continuing and/or current medical problems/conditions?* Yes No If yes, state Medical Problem/Condition*Primary Care Veterinarian*Is your pet on medication(s)?* Yes No List Medication(s):*Name of medicationDoseFrequency Add RemoveAll medications and supplements must be brought in their original containers* I have read and agree to these instructions. **If yes, to either question, a Doctor will determine if a Medical Examination of your pet is necessary. I understand that it may be determined that my pet will need to reside in the treatment area for the duration of the boarding stay.* I understand I understand that in some cases pets experience stress while boarding, this may cause diarrhea.* I understand Bathing* If needed, please bathe my pet. I accept full responsibility for all costs involved. I decline the option of having my pet bathed. I accept responsibility for all fees incurred during the boarding of my pet. I understand that my pet must be current on vaccinations and that a flea and tick treatment is required upon arrival for all pets staying at the resort. I am aware that no personnel are on premise for 24-hour care. I hereby release Family VetCare and its representatives from any and all liability for any injuries or illnesses incurred while my pet is boarded. I also understand that Family VetCare is not responsible or liable for any personal property brought with my pet, this includes any damage, cleanliness and/or loss that may occur.* I accept Pet Owner Signature*EmailThis field is for validation purposes and should be left unchanged. Δ