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 AM PM Till Appointment Date Format: MM slash DD slash YYYY Time : HH MM AM PM Pets Name #1SelectionCanineFelineBreedSexMaleFemaleNeuteredSpayedApproximate weightAge, Years, MonthsPets Name #2SelectionCanineFelineBreedSexMaleFemaleNeuteredSpayedApproximate 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 Hospital I 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
