Heart of Ankeny Animal Hospital

701 Ordnance Rd.
Ankeny, IA 50023

(515)635-0095

www.heartofankeny.com

Daycare Waiver

Daycare waiver form is required to be completed once annually for ALL daycare clients. We may also ask you to re-submit the form anytime our policies are updated. To ensure efficiency at check in please review our polices here and then scroll down to complete and submit the form online. 

Daycare Waiver Form

Daycare Waiver Form (Required once annually per client)
Date (required) :
Client/Patient Information
Client Name (required)

Email Address

Patient name(s) (required)

Social Media Consent
Can we use photos of your pet(s) on our business social media pages? (required)

Yes
No


In the event of an emergency (check one): (required)

(Option 1) Treat my pet as needed. Do all diagnostic tests, treatments, and procedures necessary for the well being of my pet. I accept full financial responsibiliy for all charges related to the treatment of my pet.
(Option 2) Treat my pet as needed. Do all diagnostic tests, treatment and procedures necessary for the well being of my pet not to exceed a certain dollar amount (entered below). I accept full financial responsibility for all charges related to the treatment of my pet.
(Option 3) DO NOT perform any diagnostic tests, treatments, or procedures on my pet until I, or my emergency contact can be reached.


If you selected Option 2 above, please enter the dollar amount not to exceed.

Emergency Contact (required)

Emergency contact phone number *We will attempt to contact you first, if you cannot be reached we will call your emergency contact next.* (required)

By checking this box I agree that I have reviewed and understand the most current Boarding and Daycare Policies listed on this website. I also confirm that the information I have provided above is accurate to the best of my knowledge.

Verify the reCAPTCHA: