Release For Care Of Kenneled Pet

Your First Name:
Your Last Name:
Phone Number:
Email Address:
Emergency Contact (Authorized Agent) First Name:
Emergency Contact (Authorized Agent) Last Name:
Emergency Contact (Authorized Agent) Phone Number:
Pet Name:
Boarding Start Date & Time:
Boarding End Date & Time:


To avoid charges, Animal Health Care, P.C. requires a 48 hour cancellation of any of the above scheduled days.



I UNDERSTAND ALL DOGS WILL RECEIVE A DISCOUNTED $10.00 BATH PRIOR TO RELEASE and if my pet repeatedly soils itself, a bath will be given and I will be charged a set fee based on my pet's weight. Charges for baths are as follows: Up to 20 lbs. $23.00. 21 lbs. - 60 lbs. $25.00. Over 61 lbs. $27.00.



If your pet requires administration of medication while boarding, there will be a base charge of $6.50/day for the first medication and an additional $1.00/day for each additional medication.



I am aware that I need to pick up my pet by the Boarding End Date and Boarding End Time as specified above.



I can be reached at the phone number specified above during my vacation. If I cannot be reached, my Emergency Contact can act as my Authorized Agent and can be reached at the Emergency Contact (Authorized Agent) Phone Number as specified above.



Would you like a nail trim for $16.50 for your pet while they are here? Please Initial. YesNo

Treats (how many per day)?
Feeding Instructions:
Medical History:
Came in with:


Check to confirm submission.


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