Lodging Information Form

Owner's Name *

First

Last

Email *

Phone *

Patient's Name

Check-In Date *

Check-Out Date *

Is your pet currently on any medications? Please list all medications, amount given, how often given, when given, and when the next dose is due.

What is your pet currently eating and how often? We feed OM or EN dry if a pet’s own food is not brought with them, Country Friends will then feed twice daily in the morning and evening unless directed otherwise. If your pet is not eating we will offer canned food (EN, OM or Recovery) which may incur additional charges. Will you be bring your own food or using ours? Please list how much and the frequency to feed.

Are any of your belongings going to stay with your pet during his/her stay with us? If so, please list:

Is your pet getting a bath during his/her stay?

If my pet needs medical attention during his/her stay, the staff at Country Friends Veterinary Clinic - 1. HAS 2. DOES NOT HAVE - my permission to provide treatment and/or can food at an additional cost to me.

Has
Does Not

All animals admitted must be current on vaccinations and be free of external parasites. Animals not in compliance with the above policy will be treated at owner’s expense. Any estimate of charges or fees for presently planned procedure(s) is only a best approximation and the final bill may be greater or less than this amount. *

I have read the above conditions for treatment and acknowledge that I may have a copy of this form, if requested.

All fees for services are due when patient is released.

I have read and understand.

Emergency Contact Numbers:

Owner/Agent’s Signature: *

Today's Date *

Name