Boarding Release Form

Home Phone (with area code):
Alternate Phone (with area code):

E-mail Address:

Pet's Name:
Type of Pet: Breed:	Select 1DogCatBirdRabbitFerretGuinea PigOther

Date you will drop off your pet:
Date you will pick up your pet:

Please read the following and respond:

By indicating I agree and submitting this form, I hereby authorize and direct the veterinarians and staff of Dale City Animal Hospital to board my pet during the above-specified period. I certify that my pet is free of external parasites and contagious disease at presentation to the best of my knowledge. I authorize the hospital to perform any diagnostic or treatment procedures deemed necessary for my pet.

I have read this statement and

I agree I do not agree

with its stipulations.

Please read the following and respond:

By indicating I agree and submitting this form, I acknowledge that I understand that current bordatella (dogs only), distemper, and rabies vaccines and a current fecal test are all required for pets before admission to the hospital. For those pets not current, vaccines and a fecal test will be updated as long as it is deemed safe and advisable by a veterinarian.

I have read this statement and

I agree I do not agree

with its stipulations.

Please read the following and respond:

By indicating I agree and submitting this form, I certify that my pet is free of all external parasites upon signing this release. If parasites, such as ticks or fleas, are found, I understand that my animal will be treated on admission for an additional cost.

I have read this statement and

I agree I do not agree

with its stipulations.

Other services desired at additional cost: (Check all that apply.)

Distemper Vaccine	Rabies Vaccine	Bordatella Vaccine
Heartworm Test	Lyme Vaccine	Feline Leukemia Vaccine
Fecal Test	Feline Leukemia Test	Anal Gland Expression
Flea Treatment	Bath	Nail Trim
Medication Refill (Doctor's approval required.) Please enter name of medication:

Please list current medications, including the name of the medicine, dosage, frequency, nad when last given:

Name	Dosage	Frequency	When Last Given

Emergency Contact Name:
Emergency Contact's Phone (with area code):

Please call us for our current boarding fees.

Thank you for boarding your pet at Dale City Animal Hospital. Please note that animals are only released during regular business hours.