Canine Influenza Waiver Form

CANINE INFLUENZA WAIVER AND SERVICE AGREEMENT

WHEREAS

WHEREAS, Facility Name: operates animal care services including boarding, daycare, grooming, and training; and

WHEREAS, Owner Name: is the legal owner or authorized agent of the canine described below and desires to engage the services of the Facility under the terms set forth in this Agreement;

NOW, THEREFORE, in consideration of the services to be provided and the mutual covenants contained herein, the parties agree as follows:

OWNER & CANINE INFORMATION

CANINE DETAILS

Dog Name: Breed: Age:

Sex: Male    Female    Spayed/Neutered:

Microchipped: Chip ID:

VACCINATION & HEALTH DISCLOSURE

I certify that to the best of my knowledge my dog is free of contagious illnesses at the time of drop-off, including but not limited to respiratory infections. I further confirm the following vaccination status (check all that apply):

Rabies    Bordetella (Kennel Cough)    Canine Influenza (if applicable)

Has the dog been exposed to any dog with respiratory illness within the past 21 days?   Yes    No

SCOPE OF WORK

Describe services to be provided (select and describe as applicable). Use the box below to specify special instructions, boarding requirements, behavior concerns, or additional services.

PAYMENT TERMS

Service Fee (total due for agreed services): $

Deposit required at booking: $ Balance due on or before pickup: $

Payment schedule (if installment):

Late fee for unpaid balances:

TERM AND TERMINATION

Service Start Date: Service End Date:

Either party may terminate this Agreement by providing written notice to the other party at least days prior to the intended termination date. Facility reserves the right to terminate services immediately for cause, including but not limited to the dog's illness or aggressive behavior.

WAIVER, RELEASE, AND ASSUMPTION OF RISK

Owner acknowledges and understands that canine influenza and other respiratory illnesses are contagious and that vaccination and other preventive measures do not guarantee that a dog will not become infected. Owner voluntarily assumes all risks associated with the presence of contagious disease, including but not limited to illness, veterinary costs, quarantine, and the potential for severe or fatal outcomes.

To the fullest extent permitted by law, Owner releases, waives, and forever discharges Facility, its owners, employees, agents, contractors, and representatives from any and all claims, demands, actions, causes of action, liabilities, losses, damages, or expenses (including attorney fees) arising directly or indirectly from the transmission, contraction, or consequences of canine influenza or any other communicable disease occurring while the dog is in the care of Facility.

INDEMNIFICATION

Owner agrees to indemnify, defend, and hold harmless Facility from and against any and all claims, damages, losses, liabilities and expenses (including reasonable attorney fees) arising out of Owner's breach of this Agreement, the dog's actions, or Owner's failure to disclose relevant health information.

MEDICAL AUTHORIZATION & CHARGES

In the event the dog requires veterinary attention while in Facility care, Facility is authorized to seek medical treatment as deemed necessary by Facility. Owner authorizes Facility to arrange veterinary care and to incur reasonable medical expenses on Owner's behalf up to $ without prior approval. For expenses exceeding that amount, Facility will make reasonable efforts to contact Owner; however Owner understands that delay may not be in the dog's best interest.

Owner agrees to reimburse Facility for all veterinary and related charges plus any administrative fees within days of notification.

QUARANTINE, ISOLATION & NOTIFICATION

If Facility reasonably suspects the dog has been exposed to or shows signs of a contagious disease, Facility may isolate or quarantine the dog for a period necessary to reduce risk to other animals and staff. Owner consents to this isolation and agrees that Facility may seek veterinary evaluation and treatment during such isolation. Owner will be notified promptly of any such determination.

CONFIDENTIALITY

Facility will maintain reasonable confidentiality regarding Owner's personal information and the dog's medical records. Facility may disclose information to veterinarians and emergency responders as necessary for the dog's care, and as required by law. Any non-public health information will not be disclosed without Owner's prior written consent.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the jurisdiction selected by the parties: Governing Jurisdiction: . Any action to enforce this Agreement shall be brought in a court of competent jurisdiction in that jurisdiction.

ENTIRE AGREEMENT

This Agreement, including any attachments and representations made herein, constitutes the entire agreement between Owner and Facility with respect to the subject matter hereof and supersedes all prior or contemporaneous oral or written agreements, representations, and understandings. Any modification must be in writing and signed by both parties.

ACKNOWLEDGMENTS

By signing below, Owner acknowledges that Owner has read this Agreement in its entirety, understands its terms, and agrees to be bound by them. Owner certifies that all information provided is true and complete to the best of Owner's knowledge.

Owner initials acknowledging receipt of Facility's illness and vaccination policy:

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