EmailMe Form - Time Saver Form

EmailMeForm

Name *
First Last
Email *
Please re-enter your email to confirm:

Confirm
Subject *
Your Phone Number *
### - ### - ####
Your Pet's Name *
Today's Date *
MM / DD / YYYY
Drop-Off Date: Please note while we usually can accommodate our guests on the dates needed, we will get back to you as quickly as possible to confirm availability. *
MM / DD / YYYY
Pickup Date *
MM / DD / YYYY
Pickup time is 12 noon. If you wish another time and know in advance, you can let us know your preferred time here.
Pickup hours: M-F 7:30 am-9:00 pm. Sat. 7:30 am-4 pm. Sun. 10:00 am-4:00 pm.
HH : MM AM/PM
Please note charges may apply for pickup after 12:00 pm. See info above this form for details.
Emergency Contact Phone *
### - ### - ####
BATH/HAIRCUT ON PICK-UP? (RECOMMENDED) *
Yes
No
NOTE: If you want your furry friend to have a bath or haircut on pickup, you can let us know details in advance with our Grooming TimeSaver form (link above form), or when you arrive.
IS YOUR PET ON A SPECIAL DIET? *
Yes
No
If yes, your pet is on a special diet, please describe
Is your pet on any medications? *
Yes
No
NOTE: If yes, your pet is on medications, please list below
Medication 1, name, dosage, frequency
Medication 2, name, dosage, frequency
Medication 3, name, dosage, frequency
Medication 4 or more: If any other medications, please write in names, dosage and frequency
Has your pet been medicated today? To be filled in on day of drop-off
Yes
No
Any special instructions?
Signature *
Clear
SIGNATURE OF OWNER/AUTHORIZED AGENT - Please sign your name and date using your mouse or stylus in the box above, to be initialed at time of drop-off on our printout of this form.

The above signed hereby warrants that he/she is the owner, or authorized agent for the owner, of the above named animal(s) and does hereby request, consent and authorize CENTER-SINAI ANIMAL HOSPITAL, its veterinarians, and staff, to board, care for and treat the said animal.

The above signed acknowledges that no guarantees have been made except reasonable precautions against injury, escape, or illness with the understanding that the undersigned will remain fully responsible for the cost of all services provided by CENTER-SINAI ANIMAL HOSPITAL, its veterinarians, and staff.
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