Mooresville Animal Hospital2681 Charlotte Highway(21 S)Mooresville, NC 28117(704) 664-4087 Boarding and Day Care Release Form Please fill out and return to the office: Today's Date:Client ID:*Patient ID:*Client Name:*Name:*Address:*Species:*Telephone*Sex:*Color:*Markings:*BirthDate: Date Format: MM slash DD slash YYYY SERVICES:Please Select any that ApplyDate Given Date Format: MM slash DD slash YYYY Vaccine Description*Date Due: Date Format: MM slash DD slash YYYY Dog Required* Select All DHPP BORDETELLA RABIES FECALCats Select All Feline Distemper Rabies FecalGrooming* Bath Only $25 MINI GROOM (bath, nails, face, feet and sanitary trim) BATH, BRUSH, NAILS, EARS DESHED HAIRCUT (MUST SEE/TALK TO GROOMER FIRST)(ONLY OFFERED MONDAY - FRIDAY. IF GROOMER IS HERE, PLEASE SEE HER TO CONFIRM AVAILABILITY)EXTRA SERVICES NAIL TRIM ONLY (INCLUDED WITH ANY GROOMING)) ANAL GLANDS EAR CLEANING VETERINARY CARE(PLEASE EXPLAIN):* Additional 15 min of Activity Participate in Day Care or Senior SocialsBoarding/Day Care Information and Release *** THIS INFORMATION WILL BE UPDATED EVERY 6 MONTHS. IT IS THE PET OWNER'S RESPONSIBILITY TO NOTIFY MOORESVILLE ANIMAL HOSPITAL OF ANY CHANGES IN THEIR PET'S INFORMATION. *** Dietary Needs:How often should we feed your pet:*If food is not pre-packaged, how much should we offer:*If you have not brought your pets a typical diet, then we feed our boarding animals Royal Canin Gastrointestinal food as sometimes a quick dietary switch can upset their stomachs. There is an additional charge for feeding this diet of $4.75 /day.*Prevention:What Type of flea and tick prevention do you use?*When was the last dose?*Medications and Medical Needs:Any medications/supplements needed:*Physical Limitations or Health Concerns:*Allergies?*Personal Belongings:Please list:*Pet Behavior Profile:Has your pet been boarded or in Day Care before?YesNoDoes your dog get along well with smaller dogs?YesNoDoes your dog get along well with larger dogs?YesNoDoes your dog get along well with puppies?YesNoIf you answered "No" to any of the last 4 questions, please explain:Does your dog prefer male or female playmates?MaleFemaleEitherIs your dog sensitive to touch on any part or area of their body?* No YesIf yes, Please explain*Does your pet have any special commands? If so, please write them here:*Has your pet ever? (If yes to any of these questions, Please explain)Growled at anyone?* Yes NoExplain*Bitten or snapped at anyone?* Yes NoExplain*Reacted Negatively when food or toys are taken away?* Yes NoExplain*Been in an alercation with another animal?* Yes NoExplain*Does your pet have any issues in the following areas? Please check all that apply. Mouthiness (hands or clothing) Excessive Barking Anxiety Fence Jumping Digging Jumping Coprophagia (Eating Feces) Destructive ChewingDaily Rates:Boarding: $29Medication Administration: $5/DayFood Provided by MAH:$4.75/DayDay Care: $17/DaySenior Social:$15Waivers:1. I hereby represent that I am the legal owner of the pet(s) described above to use the services provided by Mooresville Animal Hospital Daycare & Boarding. 2. I hereby waive and release Mooresville Animal Hospital, and it’s employees, from any and all liability which my dog(s) may suffer, including specifically, but not without limitation, any injury or damage whatsoever arising from the pet(s) attendance and participation of services provided by Mooresville Animal Hospital. 3. I hereby agree to hold harmless Mooresville Animal Hospital; it’s employees, from any and all claims by any member of my family or any other person accompanying me to a function of Mooresville Animal Hospital, or while attending the premises thereof. 4. I hereby represent that my pet(s) is of good health and has not been ill with any known contagious diseases within the past 30 days. 5. I recognize that the health of the pet(s) is the owner’s responsibility. I hereby represent that all required vaccinations (rabies, bordetella, distemper parvo and fecal) are up to date. I will also continue to ensure that the required vaccinations will be kept up to date for as long as my pet(s) attends Day Care or Boarding. In addition, I hereby represent that my pets have flea/tick preventative treatments applied regularly. 6. I further understand and agree that in admitting my pet(s), Mooresville Animal Hospital has relied on my representation that my pet(s) is in good health and has not harmed, shown aggression or threatening behavior towards any other person or any other pet. 7. I further understand and agree that Mooresville Animal Hospital and their caregivers will not be held liable for any problems that might develop with my pet(s) including, but not limited to sickness, disease, injury, running away and death, provided that reasonable care and precautions are followed. 8. I understand and agree that any problem that develops with my pet(s) will be treated as deemed best by the care-givers of Mooresville Animal Hospital at their sole discretion and that I assume full financial responsibility for any and all expenses incurred. If fleas, ticks or intestinal parasites are noted while in the care of Mooresville Animal Hospital. Treatment will be provided, and owner will be responsible for the cost. 9. I agree that my pet(s) may be videotaped, photographed and or recorded. Mooresville Animal Hospital shall be the exclusive owner to the results and all proceeds of such media. 10. Mooresville Animal Hospital reserves the right to permanently remove a pet from care at any time to ensure the safety of other pets as well as staff. 11. I understand that the rules above apply to any pet(s) of mine attending daycare and boarding.Emergency Contacts: Please make sure at least one contact is local.Name*Phone NumberName*Phone NumberName, Date and Signature:Print Name*Signature*Date Date Format: MM slash DD slash YYYY Witness* This iframe contains the logic required to handle Ajax powered Gravity Forms.