DROP OFF / BOARDING FORM
Jerry Williams
Treatment Form NEW FORM TREATMENT FORM
Owner Last Name: ____________________________ First Name: ________________________ Phone Number: ____________________
Pet Name: _____________________________ Emergency Contact: __________________________ Phone: _________________________
Please check Yes or No (Additional Fees apply):
Do you want a bath for your pet? Y___ / N___
Nail Trim? Y___ / N___
Brief Ear Cleaning? Y___ / N___
Is your pet current on all vaccines? Y ___/ N ___ Is your pet current of heartworm/ flea/ tick prevention? Y___ / N___
If no, may we update your pets' vaccines today? Y___/ N___ If not, may we administer prevention today? Y___ / N___
Vaccines/ Services to be performed during your pets visit (Additional fees apply):
DHLPPC ____ DHPPC___
Bordetella ____ Leptospirosis____
Rabies____ Fecal ____
Microchip____
Influenza ____ FVRCP____
Heartworm Test_____ FELV____
Sometimes a pet objects to us trying to help him/her and becomes irritated enough so that we cannot accomplish our goal. Should this occur, may we sedate your pet to
complete the work? If so, there will be an additional fee for sedation. NCAH hospitalizes sick pets and if your pet is not fully vaccinated he/ she may be exposed to
contagious viruses
YES you may sedate
NO you may not sedate
Treatments To Be Performed Today: __________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Special Food or Medication: __________________________________________________________________________________________ Time Fed/Medicated: _______________________________________________________________________________________________ Additional Notes/ Comments: _________________________________________________________________________________________ Pets Belongings (Please list): __________________________________________________________________________________________
In the event of a medical emergency, I give the doctors permission to treat my pet as needed and agree to cover the fees associated with such treatment. Aggressive pets may incur additional handling fees. **Pets having treatments will be released after 4:30 p.m.**
Client Signature: ______________________________________________________________
Date: __________________________
THANK YOU FOR CHOOSING NORTH CHANNEL ANIMAL HOSPITAL FOR YOUR PETS' VETERINARY NEEDS!
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