Pet Name (my "Pet"): * Veterinary Practice (my "Veterinarian"): * Owner's Name (the "Owner"): * Address:
* Email *
Phone Number(s): * Emergency Contact Name(s): * Emergency Contact Number(s): * CONSENT TO BOARDING, TREATMENT AND RELEASE OF LIABILITY
I, being at least 18 years of age, the legal owner or one of the legal owners of ( my "Pet"), or the authorized agent acting on behalf of the Pet's legal owner (the "Owner"), do hereby entrust Gochenauer Kennels, Inc.
("Gochenauer") to care for my Pet, for his/her boarding stay during all dates in the calendar year 2019, consent to his/her medical treatment as stated herein and, as the Owner, do hereby agree to all of the terms listed below and represent and warrant that all of the statements below are true, accurate and correct. I understand that this agreement creates binding legal obligations between myself and Gochenauer and I have read it carefully.
1. Boarding Charges
I agree to pay the daily boarding rate for my Pet in addition to any extra services or products requested by me. I have been fully informed and understand of the posted hours that I can drop off and pick up my Pet and I understand that I am charged for the full day that my Pet is dropped off, no matter the time of day. I understand that, from Monday to Saturday, if I pick up my Pet before 11 :00am, I will not be charged the daily boarding rate for that day. I understand that, if I pick up my Pet after 11 :00 am on such day, I will be charged for the full day. I am also aware that if my Pet is picked up on a Sunday, then I am charged for the full day regardless of the pick-up time.
2. Vaccinations and Conditions
My Pet has had all of the vaccinations required by Gochenauer from his/her veterinarian and I have provided Gochenauer with documentation evidencing that such vaccinations are current. I understand that Gochenauer, in its sole judgment and discretion, will take all necessary precautions and actions with respect to the health and well-being of my Pet. I understand that my Pet can become infected with Canine Influenza Virus (dog flu) or Tracheobronchitis ( canine cough), or such other airborne viruses, during his/her stay with Gochenauer. My Pet has been vaccinated by my Veterinarian for these viruses according to their protocol, and I will not hold Gochenauer responsible for the cost incurred for such treatment or if my Pet develops these viruses. I will seek advice from my veterinarian if either of these viruses develop. I further understand that, should my Pet have any physical or behavioral conditions that may cause him/her to be a hazard to itself, or another animal or person that I have a legal obligation to disclose this information to Gochenauer prior to my Pet's stay.
3. Medical Decisions *
I authorize Gochenauer to do whatever they deem necessary, in their sole judgment and discretion, for the health and well-being of my Pet and agree to pay for any and all expenses relating to his/her care, or to reimburse Gochenauer for such costs it incurs in the course of caring for my Pet. If my pet should require medical attention while in their care, I understand that Gochenauer will first attempt to contact me if time permits, to inform me of the condition, and also attempt to contact my Veterinarian to schedule an appointment. However, should the nature of my Pet's illness require an office visit, I understand that Gochenauer may take my Pet to whatever veterinarian it chooses in its sole discretion.
IF MYSELF, OR MY EMERGENCY CONTACT ARE UNREACHABLE, I GIVE MY CONSENT TO AND AUTHORIZE GOCHENAUER TO ACT AS MY AGENT AND TO SEEK CARE AND MAKE MEDICAL DECISIONS FOR MY PET ACCORDING TO GOCHENAUER'S SOLE JUDGMENT AND DISCRETION IN CONSULTATION WITH A LICENSED VETERINARIAN, AND I AGREE TO PAY FOR THOSE SERVICES FOR MY PET, OR REIMBURSE GOCHENAUER FOR SUCH COSTS, AT (PLEASE CHECK ONE): 4. Euthanasia Authorization (in Severe Cases Only; please check YES or NO) *
If my Pet is suffering and/or has lost all quality of life, and the veterinarian caring for my Pet recommends that he/she be euthanized, I hereby authorize and request euthanasia for my Pet. If I check YES, I understand that I am responsible for the costs of this procedure. Ifl check NO, and in accordance with my selection in sections 3 and 4 above, I agree to pay for those services needed to attempt to keep my pet alive, or reimburse Gochenauer for such costs.
5.Release of Liability and Indemnification; Limitation of Liability
To the fullest extent permitted by law, I release Gochenauer and its owners, officers, directors, employees, agents and representatives (the "Gochenauer Parties") from any injury, harm, damage or death which may occur to my Pet and agree to release and hold harmless the Gochenauer Parties from and against any and all claims, liabilities, suits, actions, administrative proceedings, costs, fines, losses, penalties and damages, including, without limitation, reasonable attorneys' fees (collectively, "Damages") related to my Pet's stay with Gochenauer. I agree to indemnify, defend and hold harmless the Gochenauer Parties from and against any Damages to another pet, person or property related to my Pet's stay with Gochenauer, except in cases of gross negligence or willful misconduct by Gochenauer. Notwithstanding the foregoing, in the event that Gochenauer is held liable for any damages, I agree that their liability shall not exceed the total amount I have paid Gochenauer in calendar year 2019.
I HAVE READ THIS AGREEMENT ON THIS DATE: *
Date Format: MM slash DD slash YYYY
I UNDERSTAND ITS TERMS AND SIGN IT FREELY. IF I AM SIGNING THIS DOCUMENT ELECTRONICALLY, I ACKNOWLEDGE AND REPRESENT THAT MY ELECTRONIC SIGNATURE (IN SUCH FORM AS IT APPEARS BELOW) IS AUTHENTIC AND LEGALLY EQUIVALENT TO A MANUAL,