Animal Medical Clinic- Boarding Admission Form

Step 1 of 7

14%

Boarding Policies

The health and safety of our boarding patients is very important to us. If we do not have documentation of a current examination and vaccinations, we will provide those services at an additional charge to boarding.
Canine vaccines and testing required for boarding: Rabies, Canine Distemper Parvo, Bordetella, Canine Influenza, Negative Intestinal Parasite test
Feline vaccines and testing required for boarding: Rabies, Feline Distemper, Negative Intestinal Parasite test
In order to keep your pet comfortable and safe from exposure, we will treat any parasites noticed on your pet.
Please make financial arrangements with a receptionist in advance if your pet will be picked up by someone other than yourself.
Drop off & Pick up times for your pet are between 9 am - 4pm.

Pet Name(Required)

Client Name(Required)

Admission Date(Required)

MM slash DD slash YYYY

Discharge Date(Required)

MM slash DD slash YYYY

Emergency Contact Name(Required)

Emergency Phone Numbers(Required)

Boarding Information

If you have more than one pet boarding, are they allowed to be housed together?(Required)

Yes

Does your pet have a history of digging or fence jumping?(Required)

Yes

Did you bring any personal items to be returned at end of pets stay?(Required)

Yes

If yes, please list items and provide description(Required)

Do you have medications that need to be given during the pet's stay?(Required)

Yes

Medication List

Medication 1

Name/Type of Medication

Example Deramaxx(Required)

Strength/Concentration

75 mg(Required)

Dosage

½ tablet(Required)

Frequency

Twice Daily(Required)

Add 2nd Medication?(Required)

Yes

Medication 2

Name/Type of Medication

Example Deramaxx(Required)

Strength/Concentration

75 mg(Required)

Dosage

½ tablet(Required)

Frequency

Twice Daily(Required)

Add 3rd Medication?(Required)

Yes

Medication 3

Name/Type of Medication

Example Deramaxx(Required)

Strength/Concentration

75 mg(Required)

Dosage

½ tablet(Required)

Frequency

Twice Daily(Required)

Add 4th Medication?(Required)

Yes

Medication 4

Name/Type of Medication

Example Deramaxx(Required)

Strength/Concentration

75 mg(Required)

Dosage

½ tablet(Required)

Frequency

Twice Daily(Required)

Add 5th Medication?(Required)

Yes

Medication 5

Name/Type of Medication

Example Deramaxx(Required)

Strength/Concentration

75 mg(Required)

Dosage

½ tablet(Required)

Frequency

Twice Daily(Required)

Add 6th Medication?(Required)

Yes

Medication 6

Name/Type of Medication

Example Deramaxx(Required)

Strength/Concentration

75 mg(Required)

Dosage

½ tablet(Required)

Frequency

Twice Daily(Required)

Add 7th Medication?(Required)

Yes

Medication 7

Name/Type of Medication

Example Deramaxx(Required)

Strength/Concentration

75 mg(Required)

Dosage

½ tablet(Required)

Frequency

Twice Daily(Required)

Add 8th Medication?(Required)

Yes

Medication 8

Name/Type of Medication

Example Deramaxx(Required)

Strength/Concentration

75 mg(Required)

Dosage

½ tablet(Required)

Frequency

Twice Daily(Required)

Add 9th Medication?(Required)

Yes

Medication 9

Name/Type of Medication

Example Deramaxx(Required)

Strength/Concentration

75 mg(Required)

Dosage

½ tablet(Required)

Frequency

Twice Daily(Required)

Add 10th Medication?(Required)

Yes

Medication 10

Name/Type of Medication

Example Deramaxx(Required)

Strength/Concentration

75 mg(Required)

Dosage

½ tablet(Required)

Frequency

Twice Daily(Required)

Date & Time Last Given

09/01/18 - 7:00 am(Required)

Is your pet a diabetic?(Required)

Yes

Diabetic Patients

Did you bring your pet’s insulin with you today?(Required)

Yes

If no, what type of insulin are you currently using?(Required)

Will you be providing syringes to be used while your pet is in our care?(Required)

Yes

If not, what type of syringes are you currently using?(Required)

U40

U100

Will you be providing syringes to be used while your pet is in our care?

Yes

If not, what type of syringes are you currently using?

U40

U100

Is your pet’s diabetes currently well regulated?(Required)

Yes

Which diet are you feeding?(Required)

How many cups and/or cans and how often do you feed your pet?(Required)

How often is your pet fed?(Required)

When did your pet last eat?(Required)

Would you like to bring your pets own food? (If not, we will feed them our clinic EN GI food).(Required)

Yes

Does your pet have any storm phobias or separation anxiety?(Required)

Yes

Does your pet have any allergies?(Required)

Yes

Medical Care

If your pet becomes ill while boarding, we will attempt to call you and/or the emergency contact provided above for consent of treatment. However, if neither can be reached and the pet needs emergency treatment, by signing this form the hospital is authorized to treat the pet. The owner will assume full financial responsibility and understands payment is due at time of service under the following guidelines:

Please Choose Only One Option(Required)

Do all that is necessary for my pet; no cost limitations.

Do not spend more than $______________ in the treatment of my pet

Do not spend more than $______________ in the treatment of my pet(Required)

Please write the amount above

Signature(Required)

Date(Required)

MM slash DD slash YYYY