Boarding Consent CompanyThis field is for validation purposes and should be left unchanged.Date In MM slash DD slash YYYY Pick up Date MM slash DD slash YYYY Pick up Time : Hours Minutes AM PM AM/PM Owner’s Name First Last Chart#Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Owner’s contactHome phoneCell phoneEmail Best means for communication: Select All Phone Text Messenger Email Pet’s NameChart #TPRWtThe following are required annual for boarding; verify at check in what is due: Select All Physical Exam Fecal Exam Bordetella Other requirements: Select All Rabies DA2PP(L) FVRCP Bathing: If pets are with us more than 3 days, a complimentary bath is performedSocialize/Exercise: While here- pets can be out of kennels to socialize with staff and house pets. If this is not allowed, please adviseOther information:DietOtherMedicationsHas your pet been ill or injured in the last 30 days? (if so explain)Consent I understand that in the event my pet becomes ill, the staff will attempt to contact me or my agent immediately to discuss the problem and treatment options. If I or my agent cannot be reached, I hereby authorize Dr B’s Healthy Pets (DBHP) to initiate appropriate treatment until I or my agent can be reached. Should EMERGENCY arise, I authorize the medical staff to sedate/anesthetize my pet and/or perform such emergency procedures as may be necessary services rendered to my pet. In the event of death of my pet, I understand the staff will immediately attempt to contact me. If I am unreachable, I understand the body will be held until I return to discuss body care and disposition.Consent I understand that the hospital is not responsible for loss or damage to personal items left with my pet, including, but not limited to, cages, dishes, toys, and bedding.Consent I will call if my pickup date changed so DBHP can plan accordingly. If I neglect to pick up my pet within 10 days of the date scheduled for discharge and do not notify you within that time period, you may assume that my pet is abandoned and are hereby authorized to proceed as you deem best and /or necessary.Owner/Agent: First Last Date MM slash DD slash YYYY