Boarding Authorization Form

Name: UPDATE - Business name
Address: 212 East Rand Rd, Mt. Prospect, IL, 60056, US
Telephone: +18473985800

We look forward to seeing your furry family members!

BOARDING AUTHORIZATION FORM

Client Name:*
First Last
Pet Name:*
Client Phone:*
Client Email:*
Emergency Contact Name:*
First Last
Emergency Contact Phone:*
Vaccine Statement - All pets must be current on the following vaccines: rabies, distemper and bordetella (kennel cough). Due to the documented failure of mail order or store bought vaccines, only vaccines administered by a licensed veterinarian will be acceptable. If vaccines are not current or not administered by a licensed veterinarian we will vaccinate your pet here today.
Are Vaccines Current?*
- Yes
- No
What Veterinary Facility were the Vaccinations Given?
Boarding Drop Off Date:*
MM slash DD slash YYYY
Pick Up Date:*
MM slash DD slash YYYY
Pick Up Time:*

: Hours

Minutes

AM/PM
Current Diet/Feeding Schedule:*
Current Medications / Dosing:
May we treat any major/minor problems we find?*
- Yes
- No
- Please Call First
May we sedate your pet if absolutely necessary?*
- Yes
- No
- Please Call First
I request the following work to be done:
Disclosure Statement Authorization - I understand that Randhurst Animal Hospital will use every reasonable precaution to assure my pet’s safety while it is in their care and expect the veterinarian to use reasonable judgment should my pet develop any health problems. I consent to the administration of treatment/ medication should a situation arise and financial responsibility for all charges incurred during my pet’s stay. I agree to my pet (s) being photographed and for their image to be used on social media.*
I Authorize Treatment/Medication/Photos
Payment in full must be received upon pet pick-up. A $25 fee will be charged for returned checks.
Authorization Date:*
MM slash DD slash YYYY
Name: (This acts as your Digital Signature)*
First Last
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Monday - Friday	8:00 am - 7:00pm
Saturday	9:00 am - 2:00pm
Sunday	Closed