I will pick up on: *

Date

Time

I can be reached at: *

If I cannot be reached, call: *

Email address, in case we cannot reach you by phone:

(Optional)

DIABETIC PETS: (Additional Fees Apply) All diabetic pets will have a blood glucose test done upon check-in and check-out.

Type of Insulin *

When was the insulin last given? *

Number of units (per dose) *

Location of injection site *

Time(s) of day *

Time pet last ate *

FEEDING INSTRUCTIONS: *

Own Food
Dry Food
Canned Only
Dry & Canned

Number of feedings per day *

How much per feeding *

Medications To Give: (Additional Fees Apply)

Medication

Next Dose Due

Medical Services Requested (vaccines with an asterisk require a physical exam)

Update required vaccines, annual test and exam: Canine (Rabies*, DaP* or DHPP*, Leptospirosis*, Bordetella, H3N8 CIV, H3N2 CIV and Fecal test), Feline (Rabies* and HCP* or FVRCP*)
Please also update all recommended vaccines, annual test and exam: Canine (Lyme vaccine* and Heartworm test), Feline (Fecal test and Feline Leukemia* vaccine)
Check vaccine and annual test history at
Request veterinarian to examine
Call before treating or treat after requested exam

Please specify

Medical, physical, or behavioral problems we should be aware of:

MEDICAL TREATMENTS OR SERVICES NEEDED: (Additional fees apply)

Bathing Instructions: (Additional Fees Apply)

Do you need an estimate for additional services not included in the daily boarding fee? *

Yes
No

BEDDING AND KENNEL ITEMS: (check preference) *

YES, my pet can have ODAH Center provided bedding or personal items left with him/her in their kennel. ODAH Center will not be held liable for any injury, illness, or loss that may occur during the boarding period, including but not limited to, loss of personal items, damage to property, injury, illness or death to my dog or other animals due to bedding, clothing, toys, etc.
NO bedding, toys or clothing should be placed in the kennel with my pet(s).

Items Left

MEDICAL EMERGENCY AUTHORIZATION:

I am the owner/authorized agent of the animal described below and authorize Old Dominion Animal Health Center (ODAH Center) to provide services as necessary to preserve the pet’s life and well-being, and I absolve and release ODAH Center from any loss, expense, or liability arising from the performance of these services. In the event of a medical emergency, outside of regular hours, ODAH Center may transport the pet to a 24-hour emergency clinic, and I authorize ODAH Center staff members to grant permission for diagnostics and treatment at that facility until I am able to be contacted. All fees incurred at that 24-hour emergency clinic and/or ODAH Center, as well as all liabilities or losses are the sole responsibility of the owner or agent. I understand that the center is closed and not medically staffed outside of regular business hours.

I ALSO ACCEPT THAT ANY MEDICAL CONDITION WE BELIEVE TO BE PUTTING THIS PET IN PAIN OR RISK, INCLUDING INTESTINAL UPSET WILL BE TREATED IMMEDIATELY AT REGULAR HOSPITAL FEES. *

I have read and agree

VACCINATIONS AND PARASITE PREVENTION AUTHORIZATION: *

I understand that my pet(s) must be current on all required vaccination and be free of fleas and intestinal parasites. I authorize my pet to be vaccinated and treated for fleas and/or intestinal parasites if necessary.

FINACIAL AUTHORIZATION: *

I accept all financial responsibility for the above services, including any emergency clinic fees, and understand that, unless agreed to in advance, these fees must be paid before the pet is released. I also accept that all boarding charges accrue per calendar day.

MULTIPLE PET FAMILY:

I authorize and instruct ODAH Center to board my pets together in the same space. I absolve ODAH Center from any liability for injury or illness that may occur as a result of this action.

ADVANCE MEDICAL AUTHOIRZATION: *

If my pet becomes critically ill and I am unavailable, I have an Advance medical Authorization form.

(This form is required for each visit for a hospital stay. Please complete the Advance Medical Authorization form.)

Pet’s Name *

Your Name *

First

Last

Number to call when my pet is ready: *

Email *

Date *

Signature *

Clear Signature

Drop off Date

Date *

Diabetic Boarding Form