Day Board Authorization Form in Lumberton, TX | Main Street Veterinary Clinic

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This field is for validation purposes and should be left unchanged.

Owner*

First Last

Check In Date*

Patient*

Age*

Years

Months

Breed*

Color*

Sex*

I, certify that I am the owner or responsible party of the patient described above, being assessed/treated today. I have the authority to execute this consent. I am over the age of 18. I hereby authorize the DVM of MSVC, PC and the facility's authorized staff or agents consent to perform said procedures.*

Initial here

My pet is here for DAY BOARDING ONLY. Should my pet need to stay overnight we do require a different form to be filled out ‘Online’ and submitted with feeding instructions, etc. Please contact us in advance of closing to be able to allot time to fill out.*

Initial here

If you beloved pet needs medication(s) while here Day Boarding, there will be a fee of $2 each time given.

**Should medical complications arise requiring emergency treatment and the veterinarian/staff is unable to reach me by immediate phone call, the dvm/staff at MSVC has permission to provide such treatment and I agree to pay for such care which may include emergency treatment and procedures up to $*

(Please Note)

Initial*

If CPR is necessary, do you want performed?*

Yes

**I understand & acknowledge that MSVC is unstaffed between hours of 6pm and 7am M-F and most hours on weekends & holidays. I understand that my pet will be left unattended during those times & during any overnight and/or boarding with MSVC. I acknowledge that I have received MSVC’s notice on its lack of fire suppression & overnight staffing. I understand & acknowledge that MSVC is not equipped with an on-site fire suppression sprinkler system.***

Client Initial

I hereby acknowledge I have been given a verbal estimate and/or option for an estimate of charges and accept financial responsibility for the care of this animal. I also understand that ALL charges will be PAID IN FULL at the time of release/pick up/discharge and that a deposit may be required. I also acknowledge that MSVC does NOT do billing of any kind. I understand that the DVM can charge as necessary for services. All prices are subject to change. By signing, I am in agreement that all services are PAID In Full at time of service.

Signed*

Date*