Lilburn-Stone Mountain Boarding Release Form

Client Name: *

Pet Name: *

Primary Emergency Telephone Number: *

Secondary Emergency Telephone Number:

Have you already made the boarding reservation? Yes No *

Is this pet currently a patient of The Village Vets? Yes No *

If not, please provide the name and phone number of the vet clinic that has the current vaccine history for this pet.

Boarding Entry Date: ... *

Boarding Exit Date: ... *

Special Instructions/ Diet/ Medications to be given while boarding:

Medical Services/ Treatments to be provided while boarding:

Please note: The Village Vets of Lilburn-Stone Mountain are not responsible for clients/pets personal items (leashes/collars/toys/bedding) that are left at VVLSM during their pet’s visit.

In case of illness or injury, I, the undersigned, do hereby give my authorization and consent for the doctors of the hospital to treat, prescribe for, or operate upon my pet(s) while they are being boarded at the hospital.

They are to use all responsible precautions against illness, injury, or escape of my pet(s), but they will not be held liable or responsible in any manner whatsoever, under any circumstances, on account of the care, treatment, or safe keeping of my pet(s), as it is thoroughly understood that I assume all risks.

Should the circumstances arise that my pet(s) remain unclaimed after the date which I have stated as the pick-up date, I understand that written notice will be mailed to my current address. Seven days after such written notice the pet(s) will be considered abandoned and may be disposed of, or destroyed, as the hospital deems best. It is further understood that such action will not relieve me from paying all costs of the services, including the cost of the boarding service.

The Village Vets of Lilburn-Stone Mountain promotes a flea and tick free environment.  If fleas and/or ticks are noted on your pet(s) upon arrival or while here, a preventative will be applied to your pet immediately, therefore there will be an additional charge of $20.00 to $25.00 applied to your bill.

My pet has been fully vaccinated within the past 12 months. If I cannot show proof of such vaccinations, then I give permission for the hospital to administer vaccinations required for the boarding of my pet(s).  With annual vaccines your pet will be examined by a veterinarian and subsequent fees will apply.

I have read and understand the authorization and consent. *

NEW CLIENTS ARE REQUIRED TO PAY FOR BOARDING AND ANY SERVICES TO BE PERFORMED WHILE BOARDING, AT THE TIME OF DROP OFF.

*Vaccinations Required*

Signature of Owner *

Date ... *