Your Name*

Pet Name*

Email Address*

Phone Number*

Please describe and list any belongings you wish to stay with your pet (leashes, toys, bedding, etc.):

Did you bring your pet's own food with you?* Did you bring your pet's own food with you?* Yes No, please feed my pet Hill's I/D (daily feeding fee will apply)

How often do you want us to feed your pet?* How often do you want us to feed your pet?* Once daily AM Once daily PM Twice daily (AM & PM) Three times daily (AM, NOON, PM) Free Fed (Food available all day) Other

How much do you want us to feed your pet? And please indicate whether they eat dry or wet food. *

Comments on Feeding: Comments on Feeding: Please feed my pets separately My pet is FOOD AGGRESSIVE My pet uses a slow eater bowl Other (Please indicate in Other General Comments}

Adding LVC Stew for Enticement* Adding LVC Stew for Enticement* YES, please add LVC stew (free of charge) to my pet’s food if enticement is needed (aka my pet is not eating) NO, my pet has FOOD ALLERGIES (Please explain in Other General Comments}

Treat Instructions: Treat Instructions: Please give treats after going potty Please give treats as desired I would like to pay for my pet to have an LVC PB kong Other (Please specify in Other General Comments}

General Comments

Does your pet need to be given medication while in our care? Does your pet need to be given medication while in our care? Yes No

Medication 1 - Name and Strength

Medication 1 Amount -- How much do you give at one time?

Medication 1 - Frequency -- How often do you give this medication?

Medication 1 - Next dose due?

Medication 1 - Special notes? (mix with food; use pill pocket, etc)

Medication 2 - Name and Strength

Medication 2 Amount -- How much do you give at one time?

Medication 2 - Frequency -- How often do you give this medication?

Medication 2 - Next dose due?

Medication 2 - Special notes? (mix with food; use pill pocket, etc)

Medication 3 - Name and Strength

Medication 3 Amount -- How much do you give at one time?

Medication 3 - Frequency -- How often do you give this medication?

Medication 3 - Next dose due?

Medication 3 - Special notes? (mix with food; use pill pocket, etc)

Let us enhance your pet's stay with VIP (Very Important Pet) Services! If you would like your pet to receive VIPs during their stay, please choose what they would like and on what day. ($11.00 per VIP) Let us enhance your pet's stay with VIP (Very Important Pet) Services! If you would like your pet to receive VIPs during their stay, please choose what they would like and on what day. ($11.00 per VIP) VIP Playgroup: my dog loves playing with other dogs VIP Private Play: my dog loves one-on-human play time VIP Snuggle Time: my dog loves to get snuggles Extra cuddle/TLC time VIP Long Walk: my dog loves to go on long walks VIP Feline: my cat loves lounging in sunny cat ward No, thank You

Please indicate the date(s) and type of VIP you would like for your pet during their stay. (example: Nov. 28 - long walk; Nov. 29 - play time)

Would you like your pet to receive spa services during their stay? Would you like your pet to receive spa services during their stay? Nail trim ($22.50) Ear cleaning ($25.50) Bath ($29.50) No, thank you

Additional Comments: Please provide any additional information you feel is important for our team to know about your pet. Example - Medicated shampoo needed, hypoallergenic diet needs, behavioral needs

I understand my pet's vaccines and intestinal parasite test must be current. If it is found that my pet is not current at the time of admission, or if I am unable to provide this information, I agree to have these services provided during my pet's stay at my expense. This may alter my pet's reservation status (if overdue more than 30 days for Bordetella or DHPP, my pet must be boarded in the Hospital Ward. There is no grace period for Rabies).* I understand my pet's vaccines and intestinal parasite test must be current. If it is found that my pet is not current at the time of admission, or if I am unable to provide this information, I agree to have these services provided during my pet's stay at my expense. This may alter my pet's reservation status (if overdue more than 30 days for Bordetella or DHPP, my pet must be boarded in the Hospital Ward. There is no grace period for Rabies).* I Understand

2. I understand my pet must be free of external parasites. A brief examination will be done upon admission to check for fleas and ticks. If external parasites are found on my pet, treatment will be required at my expense.* 2. I understand my pet must be free of external parasites. A brief examination will be done upon admission to check for fleas and ticks. If external parasites are found on my pet, treatment will be required at my expense.* I Understand

I understand that some pets develop diarrhea and/or inappetence due to stress while boarding. This condition is not uncommon and usually responds to minimal medical treatment. I understand The Playground at Lodi Veterinary Care has a protocol put in place for this situation. This protocol is to begin a bland diet (Hill's Prescription Diet I/D). This diet is also the maintenance food offered to my pet if I did not provide my pet's normal diet. There will be a daily feeding fee for this service. If the condition does not improvement with a bland diet in 24 hours, the protocol advises a veterinarian examination. There is a fee for this exam and any medication(s) dispensed. A daily medication fee will apply if medications are to be administered during my pet's stay. If my pet develops diarrhea or inappetence, I consent to one of the following terms I understand that some pets develop diarrhea and/or inappetence due to stress while boarding. This condition is not uncommon and usually responds to minimal medical treatment. I understand The Playground at Lodi Veterinary Care has a protocol put in place for this situation. This protocol is to begin a bland diet (Hill's Prescription Diet I/D). This diet is also the maintenance food offered to my pet if I did not provide my pet's normal diet. There will be a daily feeding fee for this service. If the condition does not improvement with a bland diet in 24 hours, the protocol advises a veterinarian examination. There is a fee for this exam and any medication(s) dispensed. A daily medication fee will apply if medications are to be administered during my pet's stay. If my pet develops diarrhea or inappetence, I consent to one of the following terms I Understand

If my pet develops diarrhea or inappetance, I consent to one of the following term:* If my pet develops diarrhea or inappetance, I consent to one of the following term:* Treat my pet according to the protocol outlined above, you need not call me. I authorize a bland diet only. I prefer to be called prior to any other treatment. I do not authorize a bland diet or diet change. I prefer to be called prior to any treatment.

The Playground at Lodi Veterinary Care strives to keep my pet healthy and safe while here. However, even under the best conditions, animals have unforeseen health problems. I understand that if my pet exhibits any signs of illness while here, outside of what is described and authorized in #3 above, the doctors and staff at Lodi Veterinary Care will make an attempt to call me. If I am unable to be reached, I consent to one of the following terms. In the event of a serious, life-threatening emergency, I give permission for my pet to be treated at the doctor's discretion until I can be reached. There is a fee for an exam and any additional services needed. The Playground at Lodi Veterinary Care strives to keep my pet healthy and safe while here. However, even under the best conditions, animals have unforeseen health problems. I understand that if my pet exhibits any signs of illness while here, outside of what is described and authorized in #3 above, the doctors and staff at Lodi Veterinary Care will make an attempt to call me. If I am unable to be reached, I consent to one of the following terms. In the event of a serious, life-threatening emergency, I give permission for my pet to be treated at the doctor's discretion until I can be reached. There is a fee for an exam and any additional services needed. I Understand

If I am unable to be reached, I consent to one of the following terms. In the event of a serious, life-threatening emergency, I give permission for my pet to be treated at the doctor's discretion until I can be reached. If I am unable to be reached, I consent to one of the following terms. In the event of a serious, life-threatening emergency, I give permission for my pet to be treated at the doctor's discretion until I can be reached. I authorize a doctor examination. Treat my pet as required, you need not call me I authorize a doctor examination. Do not perform diagnostics and/or treatments until I, or my emergency contact, am notified and give consent. I do not authorize a doctor examination until I have been contacted.

5. I understand that some or all of my pet's belongings may not be appropriate without supervision (stuffed toys, smaller toys, rawhides, etc.). I understand that personal items may become soiled, destroyed, or may not be able to be laundered properly, resulting in loss of these personal items. I do not hold The Playground at Lodi Veterinary Care or its employees responsible for personal belongings that are lost or destroyed. I understand that the employees reserve the right to remove any personal belongings if deemed a danger. 5. I understand that some or all of my pet's belongings may not be appropriate without supervision (stuffed toys, smaller toys, rawhides, etc.). I understand that personal items may become soiled, destroyed, or may not be able to be laundered properly, resulting in loss of these personal items. I do not hold The Playground at Lodi Veterinary Care or its employees responsible for personal belongings that are lost or destroyed. I understand that the employees reserve the right to remove any personal belongings if deemed a danger. I hereby authorize the Playground at Lodi Veterinary Care to keep my pet's personal belongings in the kennel throughout my pet's stay. I do not wish to keep my pet's personal belongings with my pet. I will take these items home with me.

6. I understand that if my pet should become soiled during their stay, a bath will be provided and charged accordingly. 6. I understand that if my pet should become soiled during their stay, a bath will be provided and charged accordingly. I Understand

7. If I chose to have two or more of my pets in the same kennel and they need to be separated during their stay, I agree to pay for the additional kennel(s). 7. If I chose to have two or more of my pets in the same kennel and they need to be separated during their stay, I agree to pay for the additional kennel(s). I Understand

Please initial if the VIP Playgroup service is requested. I agree that Lodi Veterinary Care and its employees will not be held liable for any injury or illness to my pet while cared for at this facility. I understand that, even under supervision, accidents can happen with play biting, jumping, and twisting a paw or leg, etc. I authorize The Playground at Lodi Veterinary Care and its staff to let my pet play with other pets during group playtime. Furthermore, I agree to pay for treatment of any injury or illness which necessitates treatment during playgroup if I cannot be reached for authorization of said treatment. Please initial if the VIP Playgroup service is requested. I agree that Lodi Veterinary Care and its employees will not be held liable for any injury or illness to my pet while cared for at this facility. I understand that, even under supervision, accidents can happen with play biting, jumping, and twisting a paw or leg, etc. I authorize The Playground at Lodi Veterinary Care and its staff to let my pet play with other pets during group playtime. Furthermore, I agree to pay for treatment of any injury or illness which necessitates treatment during playgroup if I cannot be reached for authorization of said treatment. I Understand

DIABETIC PATIENTS. Boarding can be a stressful event for any dog or cat. For animals with diabetes, I understand that stress can affect their blood glucose regulation. With most diabetic patients needing insulin to regulate their blood sugar levels, and monitoring of their appetite, I understand my diabetic pet will be required to be boarded in the Hospital Ward. My pet will receive special monitoring and care from certified veterinary technicians while here. There is no waiver for this. DIABETIC PATIENTS. Boarding can be a stressful event for any dog or cat. For animals with diabetes, I understand that stress can affect their blood glucose regulation. With most diabetic patients needing insulin to regulate their blood sugar levels, and monitoring of their appetite, I understand my diabetic pet will be required to be boarded in the Hospital Ward. My pet will receive special monitoring and care from certified veterinary technicians while here. There is no waiver for this. I Understand My pet is not diabetic.

SEIZURE PATIENTS. Boarding can be a stressful event for any dog or cat. For animals with epilepsy or other seizure disorders, it is a known fact that stress can trigger a seizure. I understand The Playground at Lodi Veterinary Care team takes steps to minimize stress while boarding, but it is advised that my pet is to board in the Hospital Ward. My pet will receive special monitoring and care from certified veterinary technicians while here. I agree to these conditions and my pet will be boarded in the Hospital Ward. Even though my pet has a history of seizure activity, I choose my pet to stay in the Boarding Ward. I understand the medical risk involved with this decision. SEIZURE PATIENTS. Boarding can be a stressful event for any dog or cat. For animals with epilepsy or other seizure disorders, it is a known fact that stress can trigger a seizure. I understand The Playground at Lodi Veterinary Care team takes steps to minimize stress while boarding, but it is advised that my pet is to board in the Hospital Ward. My pet will receive special monitoring and care from certified veterinary technicians while here. I agree to these conditions and my pet will be boarded in the Hospital Ward. Even though my pet has a history of seizure activity, I choose my pet to stay in the Boarding Ward. I understand the medical risk involved with this decision. I agree to these conditions and my pet will be boarded in the Hospital Ward. Even though my pet has a history of seizure activity, I choose my pet to stay in the Boarding Ward. I understand the medical risk involved with this decision. My pet does not have a seizure condition.

PUPPIES ONLY. Puppies under the age of 16 weeks are developing their immune system and are more susceptible to illness and disease than fully-vaccinated adult pets are. Puppies require more frequent breaks to reinforce potty training, to prevent accidents in their kennels, and to release energy. Because of these factors, I understand that It is the policy of The Playground at Lodi Veterinary Care for my puppy to be in the Hospital Ward where he/she will receive special monitoring and frequent breaks by staff members. I agree to age-specific conditions described below: ● Puppies under 8 weeks of age are boarded on an emergency basis only. They are housed away from other dogs due to their immature immune system. They are to be vaccinated as soon as age allows. If unvaccinated at time of admission, vaccines will be given during the boarding stay at the owner's expense. An intestinal parasite test must be performed before or during the stay. Proof of deworming is required, or to be dewormed while here. Must be free of external parasites. ● Puppies 8 weeks to 16 weeks of age. Housed in the Hospital Ward. Must be current on vaccinations as age allows. Ideally, must have Bordetella and most recent DHPP (+/-L) vaccines 1 week prior to boarding reservation for best immune protection. If vaccines are due at time of admission, vaccines will be given during the boarding stay at the owner's expense. Must have a negative intestinal parasite test, or be recently treated for intestinal parasites. Must be free of external parasites. ● Puppies 16 weeks to 6 months of age. Adult boarding (housed in Boarding Ward) is allowed for puppies over 16 weeks of age and vaccines (DHPP, Bordetella) are current for at least (7) days prior to the boarding reservation. If vaccines are due at the time of admission, vaccines will be given during the boarding stay at the owner's expense. If your pet is current on all vaccines, but has not yet received his/her Rabies vaccine due to age, vaccine schedule, or other authorized scenario, it is advised to have your pet housed in the Hospital Ward (see B above). You may elect to schedule adult boarding (Boarding Ward) until the Rabies vaccine is administered. Your pet will not be exposed to Rabies during boarding. We highly recommend daily VIP services for your active puppy. Must have a negative intestinal parasite test, and recently treated for intestinal parasites. Must be free of external parasites.* PUPPIES ONLY. Puppies under the age of 16 weeks are developing their immune system and are more susceptible to illness and disease than fully-vaccinated adult pets are. Puppies require more frequent breaks to reinforce potty training, to prevent accidents in their kennels, and to release energy. Because of these factors, I understand that It is the policy of The Playground at Lodi Veterinary Care for my puppy to be in the Hospital Ward where he/she will receive special monitoring and frequent breaks by staff members. I agree to age-specific conditions described below: ● Puppies under 8 weeks of age are boarded on an emergency basis only. They are housed away from other dogs due to their immature immune system. They are to be vaccinated as soon as age allows. If unvaccinated at time of admission, vaccines will be given during the boarding stay at the owner's expense. An intestinal parasite test must be performed before or during the stay. Proof of deworming is required, or to be dewormed while here. Must be free of external parasites. ● Puppies 8 weeks to 16 weeks of age. Housed in the Hospital Ward. Must be current on vaccinations as age allows. Ideally, must have Bordetella and most recent DHPP (+/-L) vaccines 1 week prior to boarding reservation for best immune protection. If vaccines are due at time of admission, vaccines will be given during the boarding stay at the owner's expense. Must have a negative intestinal parasite test, or be recently treated for intestinal parasites. Must be free of external parasites. ● Puppies 16 weeks to 6 months of age. Adult boarding (housed in Boarding Ward) is allowed for puppies over 16 weeks of age and vaccines (DHPP, Bordetella) are current for at least (7) days prior to the boarding reservation. If vaccines are due at the time of admission, vaccines will be given during the boarding stay at the owner's expense. If your pet is current on all vaccines, but has not yet received his/her Rabies vaccine due to age, vaccine schedule, or other authorized scenario, it is advised to have your pet housed in the Hospital Ward (see B above). You may elect to schedule adult boarding (Boarding Ward) until the Rabies vaccine is administered. Your pet will not be exposed to Rabies during boarding. We highly recommend daily VIP services for your active puppy. Must have a negative intestinal parasite test, and recently treated for intestinal parasites. Must be free of external parasites.* I Understand My pet is over 16 weeks of age.

Emergency Number* Emergency Number* I am available to contact during my pet's stay. You can reach me at the following number. I am NOT available to contact. The following emergency contact is authorized to make decisions about my pet.

Emergency Contact Name*

Emergency Contact Phone Number*

Emergency Contact Relationship*

Boarding Consent: I agree to the conditions listed above and authorize The Playground at Lodi Veterinary Care to board my pet and agree to pay for rendered services at the time of discharge. I also agree that The Playground at Lodi Veterinary Care and its employees will not be held liable for any injury or illness to my pet while boarded at this facility. Furthermore, I agree to pay for treatment of any injury or illness which necessitates treatment during my pet's stay as outlined above. I have read the above terms of this agreement and willingly consent to the terms as described. Boarding Consent: I agree to the conditions listed above and authorize The Playground at Lodi Veterinary Care to board my pet and agree to pay for rendered services at the time of discharge. I also agree that The Playground at Lodi Veterinary Care and its employees will not be held liable for any injury or illness to my pet while boarded at this facility. Furthermore, I agree to pay for treatment of any injury or illness which necessitates treatment during my pet's stay as outlined above. I have read the above terms of this agreement and willingly consent to the terms as described. I Agree

Other General Comments

Signature*