Lodging Information Form - Country Friends Veterinary Clinic

Today's Date(Required)

Email(Required)

Phone(Required)

Patient's Name(Required)

Check-In Date(Required)

Check-Out Date(Required)

Please provide the following details so that we can provide desired accommodations:

What medications are they on and how often are they administered?(Required)

How often and how much do you feed your pet?(Required)

If YES, please provide details of the food allergies:(Required)

If YES, please list the items that you will be bringing. Please note that some toys/treats may be considered unsafe to have during unsupervised time periods and Country Friends reserves the right to keep certain items away from boarders.(Required)

Any estimate of charges or fees for presently planned procedure(s) is only a best approximation and the final invoice may be greater or less than the stated estimate.

Please list any emergency contacts(Required)

I have read the above and acknowledge responsibility for the choices I have selected. I may have a copy of this form upon request.

All fees for services are due when the patient is released.

Signature(Required)

Today's Date(Required)

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