Hickory Veterinary Hospital
100 Kegman Road West
Chesapeake, VA 23322
(757) 548-1548
Boarding Release Form
Client Name: _________________________
Address: _____________________________
____________________________________
City/State/Zip: _________________________
Telephone: ___________________________
E-mail:_______________________________
Pet Name: _____________________________
Pet Species: ___________________________
Pet Breed: _____________________________
Pet Sex/Altered: _____________/ __Y_/_N___
Color: _________________ Weight: ________
Pet Birthdate: __________________________
In case of illness or injury, I, the undersigned, do hereby give my authorization and consent for the
doctors of Hickory Veterinary Hospital to treat, prescribe for, or operate upon my pet(s) while they are
being boarded at the hospital. If I cannot be reached, my emergency contact listed below has my
permission to make medical decisions for my pet on my behalf.
Hickory Veterinary Hospital is to use all responsible precautions against illness, injury, or escape of my
pet(s), but they will not be held liable or responsible in any manner whatever, under any circumstances,
on account of the care, treatment, or safe keeping of my pet(s), as it is thoroughly understood that I
assume all risks and charges for care. I hereby agree that payment in full is due at the time of pick-up or
will be pre-paid at drop-off. I acknowledge that picking my pet up prior to 2pm will not result in a charge
for that day, but picking my pet up after 2pm will result in a charge for an additional day of boarding.
Should the circumstances arise that my pet(s) remain unclaimed after the date which I have stated as the
pick-up date, I understand that written notice will be mailed to the address below. Seven days after such
written notice the pet(s) will be considered abandoned and may be disposed of, or destroyed, as the
hospital deems best. It is further understood that such action will not relieve me from paying all costs of
the services, including the cost of the boarding service.
My DOG has been fully vaccinated within the last 12 months with DAPPC, Bordetella and Rabies and has
a current negative fecal exam. The Canine Influenza vaccine is also recommended, but not required.
_________Owner's Initial
My CAT has been fully vaccinated within the last 12 months with FVRCP, has a current Rabies vaccine,
negative fecal exam and has tested negative for FELV and FIV.
_________Owner's Initial
If I cannot show proof of such vaccinations or procedures, then I give permission for the hospital to
administer vaccinations required for the boarding of my pet(s). I also certify that my pet is free of external
parasites and should they be found, I authorize Hickory Veterinary Hospital to treat my pet as needed for
such conditions at my expense.
_________Owner's Initial
NOTICE
The boarding of animals is subject to Article 4 (3.2-6518 et seq.) of Chapter 65 of Title 3.2. If your animal
becomes ill or injured while in the custody of the boarding establishment, the boarding establishment shall
provide the animal with emergency veterinary treatment for the illness or injury.
The consumer shall bear the reasonable and necessary costs of emergency veterinary treatment for any
illness or injury occurring while the animal is in the custody of the boarding establishment. The boarding
establishment shall bear the expenses of veterinary treatment for any injury the animal sustains while at
the boarding establishment if the injury resulted from the establishment's failure, whether accidental or
intentional, to provide the care required to bear the cost of veterinary treatment for injuries resulting from
the animal's self-mutilation.
Medications To Be Administered:
____________________________________________________________________________________
Pets requiring medication during their boarding stay will be assessed a medication administration fee. The
fee is varied depending on the number of medications to be administered and the time required to ensure
proper administration of all medications.
Procedures To Be Performed:
____________________________________________________________________________________
I authorize Hickory Veterinary Hospital to perform the above mentioned medical procedure(s) required for
the diagnosis and/or treatment of my pet.
I have read and understand the authorization and consent.
Begin Boarding Date: ___________________
End Boarding Date: _____________________
Is there any possibility your animal may be picked up early or stay longer? ________________________
Telephone number where the owner can be reached:
Home: ____________________
Cell: _______________________
Emergency Contact: ___________________________
Phone: __________________
I authorize Hickory Veterinary Hospital to release my pet to the following person in the event that I am
unable to pick up my pet _____________________________
____________________________________
Signature Of Owner
______________________
Date