5620 W. Maple Rd. West Bloomfield, MI 48322 (248) 851-6645

Boarding Admission Form Admission by: ____________________ Date of Admission: ________________ Expected Discharge Date: ____________ (AM) (Noon) (Early PM) (Late PM) Client Name:_____________________ Patient:________________________ Phone # 1:______________________

Phone # 2:_________________________

Emergency Contact: _______________________________________________ Contact phone number: ______________________________________________ 1. All pets boarding must be current on vaccinations. Written proof of vaccinations or verification with the pet's veterinarian must be provided before boarding the pet(s). 2. If parasites are found on the pet during the stay, they will be treated as Animal Hospital Maple Orchard determines, and the cost of the treatments will be added to the total bill. 3. If the pet is to picked up by someone other than the owner, arrangements must be made with the veterinary clinic regarding the bill. Agent: ____________________________ 4. All patients boarding must be up to date on flea prevention to prevent the spread of infestation within the hospital. Please list the prevention used:___________________ Date last applied:____________________ If your pet is not up to date on flea prevention, the technician can go over the options available in the hospital. Is your pet on any medications? { } Yes { } No If yes, please list medications: ________________________________________________________________________________________ ________________________________________________________________________________________ Is your pet on special diet? { }Yes { } No

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Please list any special instructions: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ REGARDING THE TREATMENT OF MY PET DURING ITS STAY: a) Treat my pet as needed. Do any and all diagnostic test, treatments, and surgeries necessary for the wellbeing of my pet. I accept full financial responsibility for all charges related to the treatment of my pet(s). Signature: _____________________________________ Date: _____________ b) Treat my pet as needed in the event of an emergency ONLY. I understand that Animal Hospital Maple Orchard will perform any treatment deemed necessary by the veterinarian to stabilize my pet until I can be contacted, not to exceed $750. I accept full financial responsibility for all charges related to the treatment of my pet(s). Signature: _____________________________________ Date: _____________ c) Do not treat my pet until I am able to be contacted. I understand that Animal Hospital Maple Orchard will not perform any treatment on my pet(s) until I have been notified of the suggested treatment(s), even if life threatening. Signature: _____________________________________ Date: _____________