"*" indicates required fields Step 1 of 2 50% X/TwitterThis field is for validation purposes and should be left unchanged.Client InformationName First Last PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Patient InformationPatient NameDate MM slash DD slash YYYY SpeciesSexColorMarkingsDate of Pickup MM slash DD slash YYYY Time of Pickup Hours : Minutes AM PM AM/PM Boarding Rates Are Determined By Animal Species & Weight These Rates DO NOT Include Medical Care SPECIAL INSTRUCTIONSBathing and Clean Up Charges Are Determined by Animal Species & Weight I request a bath (Canine patients only) I request a nail trim I understand that my pet will be cleaned up if soiled, and that I will be charged accordingly.Signature of legal owner or responsible personDate MM slash DD slash YYYY PLEASE READ THE FOLLOWING BEFORE SIGNING : If tranquilization / sedation is necessary for treatment or handling of my pet, I give my permission for Montgomery Animal Hospital to administer such medication(s). I understand that there is a charge for such medications. All Animals entering Montgomery Animal Hospital MUST be up to date on vaccinations and free of external parasites (fleas, ticks, etc.) or they will be treated upon entry at the owner's expense. I authorize Montgomery Animal Hospital to treat my animal should he or she develop a medical problem while boarding, and I agree to pay for all exams and treatment services rendered. I agree to contact Montgomery Animal Hospital if I am unable to pick up my pet as scheduled. I agree to pay in full for all services rendered by Montgomery Animal Hospital and to pay for those services at the time of discharge. PETS ARE RELEASED ONLY DURING REGULAR HOSPITAL HOURS. If I neglect to pick up my pet within 10 days of the scheduled date, Montgomery Animal Hospital may assume that my pet has been abandoned and will be handled at Montgomery Animal Hospital's discretion. Should I abandon my pet, I understand that I am liable for all charges incurred, that I will be reported to the authorities, and that I may be subject to prosecution. I understand that DISCHARGE TIME IS 9 AM, and that an additional day of boarding may be assessed for all animals picked up after that time. Signature*Date* MM slash DD slash YYYY What Number can you be reached while you are away? Our in-house diets are Purina EN prescription dry food and Purina ProPlan canned food. We can feed your pet either of the two or a mixture of dry and canned.* Check here if your pet will be fed our in-house diet. Check here if you are providing your pet's food during their stay. In-house dietCheck ONE of the following boxes and place a numerical value on the subsequent lines:* Dry Food Only Wet Food Only Both Wet and Dry Food Dry Food*How many cups?How many times a dayWet Food*How many can(s)?How many times a day?Provided Food Note: All food is to be labeled with your pet's First and Last Name with a permanent marker. Food Brand*How many individual bags of dry food have you brought in?*How many cans of wet food have you brought in?*Feed___individual bag(s) of dry food mixed with___can(s) of wet food___times a day.*Individual bag(s)Can(s) of wet foodTimes a dayPM Feeding*Bag(s) of dry foodCan(s) of wet foodAM Feeding*Bag(s) of dry foodCan(s) of wet foodDIETARY RESTRICTIONSAllergies*Prescription Diet Foods*OthersMEDICATIONS BROUGHT FROM HOMEMEDICATIONS BROUGHT FROM HOME*Name of MedicationStrengthDosageWhen last given Add RemoveOTHER ITEMS BROUGHT FROM HOME - PLEASE LIST BELOW:Note: Only two items (in addition to your pet's food, if applicable) can be brought in for boarding. Label all items with your pet's first and last name in permanent marker:*ItemItem Description (Color, Size) Add RemoveHave you noticed any of the following over the past month?Vomiting* Yes No Diarrhea* Yes No Coughing* Yes No Sneezing* Yes No Limping* Yes No Loss of appetite* Yes No Increased appetite* Yes No Other (Please explain here):
