South Crossing Veterinary Center
6700 Kalamazoo SE. Grand Rapids, MI 49508
Client name_____________________ Animal name_______________________
Address_____________________________ City______________________, MI
Phone_____________________________
Emergency contact person or phone number____________________________
Patient name:________________ Description: __________________________
My pet(s) will begin boarding on: _________________ and end boarding on: ____________________
Items and belongings left with Pet:______________________________________________________
________________________________________________________________________________
Does your pet have any medical conditions or problems we should know about? 
Yes No
If yes please explain:_________________________________________________________________
________________________________________________________________________________
Is your pet on any medication? Yes No If yes please explain:___________________________
_________________________________________________________________________________
( Please leave only the amount of medication needed for the duration of your pet's stay )
Does your pet have any behavioral problems? Yes No If yes please explain: _________________
__________________________________________________________________________________
Would you like your pet to receive any of the following services while here?
* Bath Yes No <20# $25.00 20-40# $26.5 40-60# $29.5
60-80# $31.00 80-100# $38.00
* Nail trim Yes No ( $14.10 )
* Clean Ears Yes No ( $19.80 )
* Fecal Examination Yes No ( $19.30 )
* Heartworm/Lyme Testing Yes No ( $43.00 )
* Check/clean anal glands Yes No ( $19.27 )
* Play times Yes No ($6.60 per 15 minute session) How many sessions each day do
you think your pet would like? .
* Update Vaccinations Yes No (We require all vaccines to be current.)
Signature of pet's owner or authorized agent:_________________________________
Printed Name ___________________________________________________________