Boarding Request Form Name* First Last Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number*Boarding From Date Format: MM slash DD slash YYYY Time : HH MM AMPM Till Appointment Date Format: MM slash DD slash YYYY Time : HH MM AMPM Pets Name #1SelectionCanineFelineBreedSexMaleFemaleMale (neutered)Female (spayed)Approximate weightAge, Years, MonthsPets Name #2SelectionCanineFelineBreedSexMaleFemaleMale (neutered)Female (spayed)Approximate weightAge, Years, MonthsAre your pets vaccines current?YesNoNever VaccinatedAre your pets current on Flea prevention?YesNoNever UsedI would like my pet to receive the following services:(at additional cost)Doctor ExamVaccinationsHeartworm TestFlea ProtectionAnnual Blood WorkUrinalysisX-rayOtherOtherGrooming Services(at additional cost)BathClean EarsShave DownToe nail trim (TNT)Anal Glands expressionWhom we may thank for referring you to Cornerstone Animal Hospital?I certify that I own or am the authorized agent for the above described pet, and I do hereby consent and authorize Cornerstone Animal Hospital and its staff to board and care for my pet while it is under their care and supervision.I understand that I will be financially responsible to Cornerstone Animal Hospital for all charges related to the physical and medical care and services for this pet. I agree that all boarding charges and fees will be paid in full at the time of discharge from Cornerstone Animal HospitalI hereby authorize Cornerstone Animal Hospital to board, care for, and provide any medical treatment deemed necessary for the pet described above while being boarded.Initial of the owner/agent*Date* Date Format: MM slash DD slash YYYY CAPTCHA
