Dog Boarding Admission Form – Veterinarians Cedar Rapids

***This is only to be completed if your pet has a confirmed reservation. If you have not made a reservation please call our office at 319-743-0554.

Patient Name*
First Last
Owner/Emergency Contact Signature:*
I confirm that I have read, understand and agree to the dog boarding policies for my pet's stay at Petersen Pet Hospital. I understand that typing my first and last name in these boxes constitutes a legal signature confirming that I acknowledge and agree to all of the terms provided.
First Last
Owner/Emergency Contact Signature:*
I confirm that I have read, understand and agree to the dog boarding cancellation policies for my pet's stay at Petersen Pet Hospital. I understand that typing my first and last name in these boxes constitutes a legal signature confirming that I acknowledge and agree to all of the terms provided.
First Last
Owner/Emergency Contact Signature:*
There will be a $50 damage fee if my pet causes damage to Petersen Pet Hospital boarding suite and/or supplies. I understand that typing my first and last name in these boxes constitutes a legal signature confirming that I acknowledge and agree to all of the terms above.
First Last
I understand and will not hold Petersen Pet Hospital responsible for conditions that are unavoidable in boarding kennels, such as but not limited to weight loss, hair loss, upper respiratory infections, bronchitis, diarrhea, and fleas. I understand all pets admitted to the clinic must be protected against communicable/contagious diseases and must be free of internal and external parasites or will be treated on discovery at the owner’s expense. Petersen Pet Hospital is to use all reasonable precaution against injury, illness, escape, or death of my pet.

I understand that in the event of my pet getting ill, a team member will immediately attempt to contact me or my emergency contact to discuss the problem and treatment options. If I am unable to be contacted immediately, Petersen Pet Hospital is authorized to initiate appropriate treatment at my expense until my emergency contact or I can be reached.
I understand that Petersen Pet Hospital is not responsible for loss or damage to personal items left with the pet, including but not limited to leashes, collars, toys, and bedding.

I will call if my pick-up date changes so you can plan accordingly. If I neglect to pick up my pet within 5 days of the date scheduled for discharge, and do not notify you within that time period, you may assume that my pet is abandoned, and I am surrendering ownership to Cedar Rapids Animal Control.

If your pet displays signs of aggression towards team members during their stay, you will be contacted and you or your emergency contact will be required to pick up your pet within 24 hours.
Owner/Emergency Contact Signature:*
I confirm that I have read, understand and agree to the dog boarding policies for my pet's stay at Petersen Pet Hospital. Type your name here confirming that you acknowledge and agree that Petersen Pet Hospital is authorized to initiate appropriate treatment at my expense until my emergency contact or I can be reached. I understand that typing my first and last name in these boxes constitutes a legal signature confirming that I acknowledge and agree to all of the terms above.
First Last
Emergency Contact #1*
First Last
Phone # for Emergency Contact #1*
Emergency Contact #2*
First Last
Phone # for Emergency Contact #2*
I give my consent to Petersen Pet Hospital to perform the following (check box for treatment options below):
- Toe Nail Trim - $16.82
- Express Anal Glands - $28.58
- Additional Treatments (fill out form below)
Additional treatments, if needed:
Owner/Emergency Contact Signature:*
I understand that typing my first and last name in these boxes constitutes a legal signature confirming that I acknowledge and agree to all of the terms above.
First Last
Date*
Date Format: MM slash DD slash YYYY
Description of items brought from home (color, pattern, etc.)
Carrier/Leash:
Toys:
Food:
Bedding:
Other:
Medications/Supplements:
1.) Drug name:
Directions:
How are the medications/supplements given at home?
When was last dose of medications/supplements given?
2.) Drug name:
Directions:
How are medications/supplements given at home?
When was last dose of medications/supplements given?
3.) Drug name:
Directions:
How are medications/supplements give at home?
When was last dose of medications/supplements given?
4.) Drug name:
Directions:
How are medications/supplements give at home?
When was last dose of medications/supplements given?
5.) Drug name:
Directions:
How are medications/supplements give at home?
When was last dose of medications/supplements given?
6.) Drug name:
Directions:
How are medications/supplements give at home?
When was last dose of medications/supplements given?
7.) Drug name:
Directions:
How are medications/supplements give at home?
When was last dose of medications/supplements given?
Additional comments/notes:
Feeding:*
- Dry Food:
- Canned Food:
Dry food amount:
Dry food frequency:
Wet food amount:
Wet food frequency:
Please enter the name of the flea and tick preventative that was last applied to your pet:*
All patients boarding at Petersen Pet Hospital must be current on a flea and tick preventative.
Date:*
Please select the date that the preventative was last applied:
Date Format: MM slash DD slash YYYY
Preference for flea prevention if needed. (choose one)*
- Credelio
- Bravecto
- Revolution/Topical

Description of items brought from home (color, pattern, etc.)

Medications/Supplements: