Lakeland Boarding Admission Form

1
(emergency contacts must be reachable and authorized to make medical decisions)
Pet’s name
Owner’s name (Last, First)
Boarding from
Boarding to
Approx. pick up time
Emergency phone 1st #
Emergency phone 2nd #
Alt. contact name & phone #
2
Please Select
Please Select
Yes
No
Physical exam?
Please Select
Please Select
Yes
No
Fecal exam?
Please Select
Please Select
Yes
No
Bath?
Please Select
Please Select
Yes
No
Nail trim?
Please Select
Please Select
Yes
No
Flea medication up to date? (if not, one will be applied)
Please Select
Please Select
Yes
No
Vaccinations up to date? (if not, choose which to update)
3
Please Select
Please Select
DHLPP
BORDETELLA
RABIES
LYME
INFLUENZA
CANINE
Please Select
Please Select
FVRCP
URI VACCINE
RABIES
FELV
FELINE
Please Select
Please Select
Yes
No
Does your pet currently have any health issues?
4
If yes, please explain
5
Medications to be administered
Name
Dose
1
Row 0, Column 0
Row 0, Column 1
2
Row 1, Column 0
Row 1, Column 1
3
Row 2, Column 0
Row 2, Column 1
1
2
3
Name
Row 0, Column 0
Dose
Row 0, Column 1
Name
Row 1, Column 0
Dose
Row 1, Column 1
Name
Row 2, Column 0
Dose
Row 2, Column 1
1 of 3
6
Last dose of medication given (date and time)
Name
Given
1
Row 0, Column 0
Row 0, Column 1
2
Row 1, Column 0
Row 1, Column 1
3
Row 2, Column 0
Row 2, Column 1
1
2
3
Name
Row 0, Column 0
Given
Row 0, Column 1
Name
Row 1, Column 0
Given
Row 1, Column 1
Name
Row 2, Column 0
Given
Row 2, Column 1
1 of 3
7
Please Select
Please Select
Yes
No
Refill medications?
If yes, list
8
Please Select
Please Select
Brought Own
Clinic Diet
Feeding instructions
Please specify
9
Please Select
Please Select
Yes
No
Does your pet have any food allergies?
If yes, list
10
Please Select
Please Select
Yes
No
Is your pet permitted to have a blanket in the kennel with him/her?
Please Select
Please Select
Yes
No
Toys?
11
Personal items LAC is not responsible for any lost or damaged items.
12
Health: All pets must be in good health. By signing this form, you (the owner) are stating your pet is in good health and has not been ill with a communicable condition in the last 30 days. Upon admission, all pets must be free of any condition which could potentially jeopardize other guests.

Vaccinations/Parasite requirements: All dogs are required to be current on DHLPP, bordetella, influenza and rabies. We highly recommend your pets to be vaccinated two weeks prior to boarding. Although we highly recommend cats to be fully vaccinated, FVRCP and rabies are required vaccinations. Though we take all possible precautions and require the best possible protection, there is still a possibility your pet may get kennel cough while boarding. All pets must be free of internal and external parasites. If parasites are found on or within your pet, they will be treated at your expense without authorization.

Life threatening emergencies/illnesses: Although we try to maintain a safe and healthy environment for your pet during boarding, it is possible that your pet may become ill or injured. If your pet should become ill while boarding, he/she will be treated by our hospital personnel and you will be charged accordingly. We will do our best to contact you.

Release of liability: I understand and agree that LAC and their staff will not be liable for any problems which develop, provided reasonable care and precautions are followed, and I hereby release them of any liability of any kind whatsoever arising from all reasonable precautions against injury, escape or dealthy of my pet.
13
Signature
Clear
14
Date
Date
Year
Month
Day
15
Email* This field is required.
example@example.com
16
Printed Name
17
Security Check* This field is required.
Should be Empty: