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Lakeside Veterinary Clinic

18 Lake Simond Rd

Tupper Lake, NY 12986

Phone: 518-359-7924

Fax: 518-359-7967



Lakeside Veterinary Clinic will use all precautions against illness, injury, or escape of my pet. However the clinic will not be held liable or responsible in any manner whatever for my animal as it is thoroughly understood that I assume all risks.

In case of illness or injury, I, the undersigned, hereby give my consent to Dr. Scranton to treat, prescribe for, and operate on my pet while it is being boarded at Lakeside Veterinary Clinic.

Should the circumstance arise that my pets remain unclaimed after the date which I have stated as the pick-up date, and that I have made no effort to contact the clinic, I understand that written notice will be mailed to the address below. Seven days after such written notice my pet will be considered abandoned and may be treated as you deem best. It is further understood that such action will not relieve me from paying all costs of your service and use of your hospital including the cost of the boarding service.

I also understand that I am responsible for the cost of any repair or damages caused by my pet in excess of normal wear and tear.

I have read the foregoing and agree:

SIGNATURE OF OWNER: _______________________________DATE: ____________________


Street __________________________City ______________________State _____Zip __________


PICK-UP DATE:____________________________PICK-UP TIME:__________________________


EMERGENCY PHONE NUMBER where I can be reached: ________________________________


Has your pet shown any recent signs of (if yes, please explain):


Vomiting: No Yes __________________________________________________________

Diarrhea: No Yes __________________________________________________________

Sneezing: No Yes __________________________________________________________

Coughing: No Yes __________________________________________________________


Has there been any other unusual behavior of which we should be aware? ______________________