Boarding Consent Form

    Thank you for choosing Ness Exotic Wellness Clinic. In order to personalize your experience and have a clear
    client profile, we need you to fill out our Boarding Consent Form below. Your data is safe with us.

    Today's date

    Email

    First Name

    Last Name

    Client Address

    Street Address

    Street Address Line 2

    City

    State

    Zip

    Boarding START Date:

    Boarding END Date:

    Primary Phone (while you're away):

    Secondary Phone (while you're away):

    Local Contact Name

    Relationship with Contact

    Contact Phone

    Street Address

    Street Address Line 2

    City

    State

    Zip

    PATIENT INFORMATION

    Patient Name

    Patient Date of Birth

    Gender

    Neutered/Spayed

    Species

    Breed

    Color

    Allergies

    If yes, please list alergies

    Diet

    Medications / Supplements / Treatments

    Please list any CURRENT medical problems, symptoms, or health/behavioral concerns:

    Please list any PREVIOUS medical problems:

    Please list any SPECIAL INSTRUCTIONS or
    information in that we should know in regards to boarding, handling, cleaning, and feeding your pet so that we
    can provide the best experience for them:

    Please list a description and amount of any ITEMS dropped off along with your pet:

    REQUIRED Avian Procedures/Testing (please provide most recent dates)

    Standard Exam Date
    (within 6 months)

    Avian Chemistry Profile
    (within 1 year)

    Avian CBC
    (within 1 year)

    Bile Acid
    (within 1 year)

    Chlamydophila: DNA PCR Swab or AB Titer
    (within 2 years)

    REQUIRED Mammal Procedures/Testing (please provide most recent dates)

    Standard Exam Date
    (within 6 months)

    Mammal Chemistry Profile
    (within 1 year)

    Mammal CBC
    (within 1 year)

    Ferrets ONLY :: Rabies Vaccination and/or Rabies Vaccination Titer

    Ferrets ONLY :: Distemper Vaccination and/or Distemper Vaccination Titer

    Digital Signature

    I hereby give consent to Ness Exotic Wellness Center to provide boarding services for my pet(s) from the
    dates indicated above. I understand that unforeseen conditions may require a medical or surgical procedure,
    immediate resuscitation, and/or treatments. I understand that I assume all risks and associated costs. If I
    am unable to be reached at the contact information I have listed above, I hereby authorize the performance
    of such procedures as necessary, and advisable for the welfare of my pet in the professional judgment of the
    veterinarians on staff at Ness Exotic Wellness Center.

    Data Privacy and Consent:

    I agree to theterms of service

    REQUIRED Reptile Procedures/Testing (please provide most recent dates)

    Standard Exam Date
    (within 6 months)

    Reptile Chemistry Profile
    (within 1 year)

    Reptile CBC
    (within 1 year)

    Fecal Exam – Direct Smear & Float
    (within 1 year)

    INNER OFFICE USE ONLY

    Exemption(s) of _________________________ services and/or testing as approved by Dr. _________________ on
    the date of ______________, due to ____________________________.