BOARDING ADMISSIONS FORM

L E X I N G T O N V E T E R I N A RY A S S O C I A T E S
DENTON ANIMAL H O S P I TA L 175 Haywood Street Denton, NC 27239 336.859.2828
C L I E N T I N F O R M AT I O N

H I C K O RY T R E E H O S P I TA L 118 S Village Drive Winston-Salem, NC 27127 336.775.2303

JORDAN H O S P I TA L 300 Highway 64 E Lexington, NC 27292 336.249.3991

Name: Home Phone:

S P O U S E I N F O R M AT I O N

Work Phone:

Cell Phone:

Name: Home Phone:

P E T I N F O R M AT I O N

Work Phone:

Cell Phone:

Name: Name:

Breed: Breed:

Color: Color:

O T H E R E M E RG E N C Y C O N TAC T

Name: Home Phone: Work Phone: Cell Phone:

I T E M S L E F T A N D S P E C I A L I N S T RU C T I O N S

Please indicate if you are leaving: Food Descriptions and Special Instructions

Toys

Bedding

HOSPITAL BOARDING POLICY:

All pets must be clear of eas and parasites. Cats must be current on Distemper and Rabies vaccines. Dogs must be current on Distemper/Parvo, Bordatella, and Rabies vaccines.

AUTHORIZATION
I hereby authorize the veterinarian and staff to do whatever is necessary in case of illness or an emergency situation for the care of the above-described pet(s). If medications are necessary for treatment, I give my permission to administer such medications and I understand there is an additional charge for this service. I assume responsibility for all the charges incurred in the care of the animal. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. Signature of client responsible for pet(s): __________________________________________ Date: __________________

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