Check in by MM slash DD slash YYYY Pet(s) Name Add RemoveFamily Pet Health Care Boarding AgreementOwner Name Account # At what number can you be reached while awayEmergency Contact/Authorized Agent phone number (other than yourself) Check in Date MM slash DD slash YYYY Check out Date MM slash DD slash YYYY Check out day Time of day (if known) Hours : Minutes AM PM AM/PM Feeding Instructions Once Daily Twice Daily Always Available Amount per feeding If both wet & dry foods are offered: Serve Separately Serve Mixed Special Feeding instructions:Has your pet had any of the following today?(If so, circle all that apply.) Breakfast Lunch Dinner MedicationsIf your pet is on medication, have they had their medications today? YES NO If so, what time? Medication commentsSpecial requests and notes Please note, Family Pet Health Care does our best to keep up with all your pet’s belongings, but we cannot be responsible for the loss or damage of any personal items during the boarding experience. Family Pet Health Care strives to keep a pest-free environment for your pet, therefore we require that any internal parasites (E.g. worms) or external parasites (E.g. fleas and ticks) identified on your pet while boarding be treated at the owner’s expense. Family Pet Health Care will take reasonable precautions against injury, escape, or death of your pet. Any animal that may require emergency medical treatment will receive it at the discretion of Family Pet Health Care. By signing, I give my permission for Family Pet Health Care to administer necessary medical and/or emergency treatment for my pet. I also agree to hold Family Pet Health Care harmless, in the absence of negligence, in connection with these procedures. I further agree to take responsibility for all costs related to any treatments or procedures received by my pet while boarding with Family Pet Health Care and agree that full payment is due upon discharge. Before signing this form please fill out and read all information. Signature of owner/agentDate MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.