Formulario Hospedaje de Mascotas en Veterinaria Hacienda Urbana

Pet Accommodation Form

Owner name *

Pet *

Email *

Address

Check in date *

Check out date *

Pick up time *

*if you wish to pick up or drop off your pet on a Sunday or a holiday, an additional charge of $650.00 will be added to your bill.

Emergency telephone number *

Write a phone number that we can call in case of any emergency.

Additional Phone number:

Write a phone number that we can call in case of any emergency.

Boarding Policy *

I agree with the boarding policy

The boarding policy establish that all pets have t bath before leaving the facility,this bath will have a RD$150.00 discount on bath fee established.

Type of food your pet uses *

1x 2x free access.

How many walks per day? *

Workouts per day *

* Cats only

Personal belongings

List all the personal belongings you are leaving with your pet (please, list everything)
1- _________________________________.
2-_________________________________.
3-_________________________________.

Additional Services that You Request

While my pet is boarding at your facility, I would like the doctor to check on my pet the next considerations.It is important for you to know that your Bill might increase for choosing this option and additional charges will be made if any additional procedure or test has to be made.
1- _________________________________.
2-_________________________________.
3-_________________________________.

During this days, my pet will require the following considerations

List them

Medications

List them

Please, choose one of the following statements, so we can take care the best we can of your pet:

I don’t give my authorization at all without my previous consent to do any additional procedure to my pet. Please, contact me before taking any action or making any decision regarding my pet.
I give my consent just when the cost is going to be no more than $_______. If the costs are more than that, please contact me first.
I authorize the appropriate treatment for my pet regardless of the cost of it, please perform all the procedures that you consider necessary, regardless of the cost.
I authorize the appropriate treatment for my pet in case of any problem that may arise in my absence, during my pet's stay at your facilities.

If you authorize the appropriate treatment, the cost of the treatment must not be more than $ _____________.

Only fill in if you choose this option in the previous question.

The payments of this services have to be totally paid by the time the client is going to do the check-out of the pet in our clinic. No exception *

I agree

Terms and Conditions *

I agree to these terms and conditions

The following should be done:
o CBC
o 4DX Test
o Physical evaluation
o Need to present your shots record, they must be updated.

An automatic charge will be made on your invoice of the amount of said procedures in case of not being up-to-date, they will be updated at Hacienda Urbana at the time of the pet enter, and it will be charged to the client's account. If the vaccination card is not from a vaccination center which has registered veterinarians in it, the vaccine is not valid, so it will have to be applied again.

The shots record has to have the labels of at least the last shots applied, and the date on those labels has to be on date with the application date of the shots. In case the owner brings the card, and it doesn’t have the labels of the shots, a formal certification made from the doctor of the center they were applied has to be presented.

The dates on the labels must be current within the range of application of the vaccine.

- It must be free of ectoparasites and have a valid product for their protection applied, with proof of when it was applied, -may be the invoice- (fleas, lice, and ticks).
- Must have your parasite controls up to date.

All these regulations are made for the safety of your pet and the wellbeing of the client and the hospital.

The client certifies that he has understood and agrees with all the specifications indicated above: read the company's policy sheet.

If the client is not agreeing, we will only perform the ones the client chooses from the services listed previously and the hospital and any of their personal is free of any action, present, or future that the client might want to take because of any unexpected situation that might occur. The client signed this document free and voluntarily and assumes any consequence that might be present, this consent represents a discharge of the hospital/clinic and all the ones involved.

Signature

Clear Signature

ID *

Identity Document

Date *