Check in date:
Check out date:
Best Contact Number for Owner:
In the event that you cannot be reached, please list an emergency contact that can authorize charges and make medical decisions on behalf of your pet:
**Please inform the receptionist if your pet has any special dietary requirements. Pets are fed Science Dietsensitive stomachs once daily unless otherwise noted.**General Terms: Merrill Animal Clinic will exercise responsible care for the safety of your pet, and to keep theboarding premises safe and properly enclosed. Pets will be fed and watered regularly, and housed in clean, safe quarters.The Merrill Animal Clinic cannot guarantee against accidents, and we cannot be liable for loss or damage caused by or to our pet guests at this facility. The owner agrees to be solely responsible for any and all damage caused by the owner's pet while it is at this resort. In the case of a natural disaster (ex. hurricanes, tornadoes, etc.) Merrill Animal Clinic can not and will not be liable in any way for the patients in the building; because of insurance regulations, employees are not allowed to enter the building in an emergency situation.Payment: The Merrill Animal Clinic charges for boarding space by the night. The owner agrees to pay the rate for boarding in effect on the day the pet is checked into the facility. The full payment balance is due upon checkout.Check-in/out Times: Check-in and check-out times are only during normal business hours. There are no Sunday check-ins or outs.Abandonment: If the pet is not called for within 10 days after the designated checkout date, the pet will be consideredabandoned and will be handled in accordance with state law.Vaccinations: Vaccinations are for the protection of your pet, we cannot make exceptions to vaccination requirements. If proof of vaccination is not on file or provided by another veterinarian, the pet will be examined and vaccinated at the owner's expense and has a higher risk of contracting an illness during their stay. Please ask a staff member about specific vaccine requirements for your pet.Feeding Instructions (circle 1): Please feed my pet once daily or twice daily.Departure Baths and Additional Services: We offer an optional bathing service to be done on the morning of pick up for our canine friends for a nominal fee. **PETS CAN NOT BE PICKED UP BEFORE 1:00 PM if they are having adeparture bath.
If you would like your canine to have a departure bath please initial here:
Please initial for additional services for a nominal fee:
NAIL TRIM (Felines or Canines):
NAIL GRINDING (Canine only):
Medications: Medications, supplements, or other items will be administered for an additional fee as directed, butmedications must be presented in their original containers with instructions for administration. There is a daily nominal fee for all medications to be administered.
Name of medication:
Treatment Authorization: Pets may experience additional stress in the lodging environment. Merrill AnimalThe clinic is devoted to providing exceptional care for guests, including geriatric pets. Your signature acknowledges that you are aware of and accept all age-related risks to your pet. The owner agrees that Merrill Animal Clinic, at its discretion, gives first aid, medication (including flea prevention), or other attention we deem necessary for the health, and safety of your pet. Merrill Animal Clinic is authorized by the owner to provide veterinary care, including emergency care, at the owner's expense. If we believe that your pet is in need of care, time permitting we will attempt to contact you before providing that care, but this document serves as our authorization to provide veterinary care for your pet. The owner is responsible for the expenses of veterinary care, whether or not you have been reached in advance. Your signature on this authorization permits Merrill Animal Clinic to make reasonable care decisions regarding your pet, and the owner agrees to pay for all costs incurred for such treatment. In the unlikely event that a pet passes away while a guest of Merrill Animal Clinic, we will contact you and discuss your options for body care with you.Monitoring: Staffing at Merrill Animal Clinic varies by season and day. If at any time a staff member is not present onthe premises, the hospital is locked, and monitored by an off-site fire and security alarm company. For staff safety, dogs are not walked between the hours of 8 pm and 7 am.I hereby agree to the foregoing as the owner of the aforementioned pet.I further certify that my pet is in good health and has not been ill with any communicable condition nor to myknowledge been exposed to any communicable diseases within the last 30 days. Moreover, I certify to the accuracy of all information given about my pet and have discussed any previous signs of aggression or threatening behavior toward any person or animal. I have read and understand the entire boarding contract
Below is the general history questions for your pet's visit. Please take the time to answer all of the questions prior to your appointment. This may be emailed back for convenience. As always, if you have any questions or concerns, please feel free to reply to this email, or to call.Reason for visit:
Brands of Heartworm/Flea prevention and last administration date :
Name of pharmacy IF NOT purchased from Merrill Animal Clinic:
Current Prescription Medications and times administered:
Current Supplements or over the counter medications with times administered:
Brand/Type of food:
Any recent changes to eating patterns or appetite:
Any changes to urination habits:
Itchy skin or ear concerns:
Past pertinent History:
Best Phone number for today and follow-up communications
PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE RENDERED. PLEASE CHECK YOURPREFERRED METHOD OF PAYMENT BELOW.We will gladly prepare a written estimate if you desire. Please ask the receptionist or doctor.I AM RESPONSIBLE AND AGREE TO PAY IN FULL THE TOTAL CHARGES FOR SERVICES RENDERED AT THE TIMEOF DISCHARGE AND ANY FEES INCURRED FOR COLLECTION OF SAID CHARGES. I UNDERSTAND THAT THE FEESARE BASED ON TREATMENT DEEMED NECESSARY AT THE TIME OF EXAM, TREATMENT OR ADMISSION ANDTHAT THE ESTIMATE FEE MAY BE RAISED OR LOWERED BY THE ADMINISTRATION OF TREATMENT, MEDICATION,SURGERY OR DIAGNOSTIC TEST.
I am the owner or authorized agent for the animal described above and I have the authority to execute this consent. Mysignature below certifies that I am over eighteen years of age.Although rare, sometimes an underlying or previously undiagnosed medical conditions can cause complications when apet is under anesthesia. I further understand that during the course of the operations or procedures, unforeseen conditionsmay arise that necessitate the performance of additional procedures deemed necessary for the veterinarian. I understandthe risks of anesthesia and surgery and authorize the doctors and staff of Merrill Animal Clinic to perform theseprocedures. I authorize the use of appropriate anesthesia and pain relief medications as needed before, during and/or afterthe procedure.I am encouraged to discuss any concerns I have about the risks with the attending veterinarian before the procedure isinitiated. The nature of the operations or procedures have been explained to me and I understand what will be done. I amaware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successfultreatment. I accept that my financial obligations remain regardless of the outcome.I am aware that my pet must be flea-free. If fleas are found on my pet, I authorize an appropriate flea treatment to beadministered. I understand that my pet must be current on rabies vaccines as well as all core vaccines (CANINE: DHPPV,BORDETELLA) (FELINE: FVRCP)To reduce the risk of complications during anesthesia, we recommend presurgical blood work.
Please initial if you would like your pet to have presurgical blood work before today's procedure:
We strongly encourage microchipping at the time of anesthesia. Our microchipping service includes inserting themicrochip and registering it with HomeAgain Microchip company.
If you would like your pet microchipped today, please initial here:
For dogs and indoor cats only: Yes, I would like my pet's nails to be trimmed after surgery *
CPR: In the event that Jitterbug should experience cardiac or respiratory arrest while being hospitalized today, you may consent for resuscitative efforts to be initiated until you can be contacted further and notified of Jitterbug status. By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor's discretion. Please initial you choice below:
I have read and understand this authorization and hereby accept and agree to the terms of the consent form.
For non-urgent questions or to learn more about our services, contact us today!
7530 Merrill RdJacksonville, FL 32277
Call Us:(904) 552-3551
At Merrill Animal Clinic, we provide the highest quality eye care to all our patients. Schedule your appointment today.
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