Southern Hills Animal Hospital

3827 Hite Street
Roanoke, VA 24014

(540)343-4155

www.southernhillsanimalhospital.com

Boarding Form

Your Name (required)
First Name (required)
Last Name (required)
Emergency Contact Name (required)
First Name (required)
Last Name (required)
Emergency Contact Phone Number (required)
Phone TypePhone Number (required)
Pet's Age (or) Birthday (required)

Pet's Name (required)

Pet's Weight (required)

Pet's Breed & Color (required)

Drop-Off Date & Time (required) :
Pick-Up Date & Time (required) :
Please Confirm Number of Days (required)

Feeding Instructions (required)
Hospital Stock
Own Food
Dry
Canned
Feeding Instructions (Include: Brand of Food, Amount, and Frequency) (required)

Belongings (Southern Hills Animal Hospital is not responsible for lost or damaged items) (required)
Toys
Collar
Leash
Bedding
Carrier
Description of Belongings (Southern Hills Animal Hospital is not responsible for lost or damaged items) (required)

Would you like to have your pet bathed? (required)
Yes
No
Bathing Instructions (NA if Not Applicable) (required)

Medications List - Please list all medications and indicate if they will need to be given today. (NA if Not Applicable) (required)

Medication Frequency - Please list the precise directions listed as listed on the prescription. (NA if Not Applicable) (required)

*If my pet is admitted as a medicated boarder, I authorize the hospital staff to administer medications perscribed by the doctors. I understand that if the medication runs out while boarding it will be refilled by the hospital, at the prescribed cost. (required)
I agree
I disagree
NA
Please describe any symptoms or health issues that we should know about and any treatments or issues that you would like to have the doctor examine (ex: Exam, Vaccines, Medication Refills, etc.) (NA if Not Applicable) (required)

Are there any other services you would like while your pet is boarded? (required)

**STATEMENT OF RELEASE**
One of the advantages of staying at our veterinary hospital is that immediate attention is available should the need arise. In the event of an emergency Southern Hills Animal Hospital reserves the right to treat immediately.
Please perform any services necessary for the best care of my pet until someone can be reached. (required) :
I authorize up to the below specify amount ($) in medical care until someone can be reached. (required)

**STATEMENT OF RELEASE CONTINUED**
In the event that my pet becomes injured or ill while boarding I authorize the hospital to provide whatever treatment is necessary for my pet (as indicated above)." If sedation is necessary for treatment or handling, I give my consent to the hospital staff to administer such medications.* I understand that I am responsible for any and all charges related to diagnosis and treatment for my pet. I realize the payment for services rendered is due upon discharge of my pet(s).
Do you agree? (by selecting "I Agree," you confirm that you agree to the above conditions). (required)
I Agree
I Disagree
Type your FULL NAME and the DATE (mm/dd/yyyy) that you are submitting this application. (This section acts as my signature and confirms that I agree to the above conditions) (required)


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