DRVC Boarding Form

Scheduled for space: ______ Dowlen Road Veterinary Center Bath: ________ Ck’d by: ________

Flea Treatment: Yes or No (Circle One)

Check in date/time: ___________

Check Out date/time: _________ Home Phone: ___________ Other Requested Treatments: _________

OWNER(s) Last Name: ______________________ First Name: __________________________ Emergency Phone # ________________

Pets Name: ________ Species/Breed: __________ Age: ____ WT _______ Client #: ____________

Boarding Fees

Circle One

Feline (All) $17.00

Canine: 1 –20 $17.00

Canine 21– 40 $18.00

Canine 41– 60 $19.00

Over 60 $21.00

General Guideline: Feeding Instructions (Please circle appropriate feeding schedule per age and weight) Puppies and Kittens 2 x per day

Weight Pediatric: (0-1year old) Adult: (1year – 7years) Geriatric: (over 7 years)

< 20 lbs - ¼ to ½ cup twice per day 1 - cup once per day 1 -cup once per day

20 – 40 lbs - 1 cup twice per day 1 ½ - cups once per day 1 ½ - cups once per day

40 – 60 lbs - 1 ½ cup twice per day 2 - cups once per day 2 - cups once per day

60 – 80 lbs - --------------------------- 2 ½ - cups once per day 2 ½ - cups once per day

80 lbs - ---------------------------- 3 - cups once per day 3 - cups once per day

IF Owner BRINGS OWN FOOD PLEASE FILL OUT THE FOLLOWING: DID O FEED ALREADY FOR TODAY?: YES/ NO

Special Food Instructions:AMOUNT: HOW OFTEN: DESCRIBE CONTAINER:

MEDICATIONS: List each Drug: Oral meds: $1.50 per time given Injections:$9.00-$15.00 per injection

Meds located:

Please circle one: ________________________ ______ times per day Already had today: Yes No

On cage/ Fridge ________________________ ______ times per day Already had today: Yes No

Or in Cubby ________________________ ______ times per day Already had today: Yes No

<<<<<<TOTAL COST PER DAY: ____________________ >>>>>>>>>>

EXTRA PLAY TIME: One on one personal outdoor playtime is available for your pet(s) each day with a variety of activities to choose from.

I request the following extra activities once a day, cost is $5.00 dollars per each additional activity(s) requested. (Please circle your request)

FRISBEE BALL TOSSING EXTRA WALKING HOLDING/BRUSHING OBEDIENCE ($5.00ea)

<<<<<<TOTAL COST PER DAY: ____________________ >>>>>>>>>>

                    Legend:  0 – Did not     √  -  Did       NAF = No Abnormal Finding     

Payment for all services rendered is expected at the time of service. I authorize treatment and surgery for my pet. I understand that medicine is not an exact science and that no guarantees of medical results have been implied. As the owner or authorized agent of my pet I hereby release Dowlen Road Veterinary Center, their agents, servants, or representatives from any and all liability arising from treatment of my pet.. I authorize the doctor to treat emergencies as deemed necessary. We require all vaccinations to be given here. Please do not bring anything larger than an 8” x 8” x 8” box. We will not be held responsible for any items brought into the clinic for your pet while boarding.

Signed ___________________________________________________________ Date _________________________

Employee Signature: _______________________________________________ Date: _______________________