Client's Name *

First

Last

Phone *

Email *

Pet's Name *

Age/Date of Birth *

Breed *

Color

Approximate Weight *

Check-In Date *

Projected Check-Out Date *

We may need to contact you or someone you trust to make medical and financial decisions. Please provide us with the two contacts and the best phone numbers for each.

Additional Person's Name *

First

Last

Additional Person's Phone *

Secondary Person's Name

First

Last

Secondary Person's Phone

Reason For Visit (please check all that apply) *

Wellness exam/vaccines
Boarding
Imaging
Medical problem

Medical problem: please explain *

Has your pet shown any of the following signs? (please check all that apply) *

If other, please specify *

New growths - please describe *

Pain/lameness - please describe *

Urinary issues - please describe *

When did your pet last eat? *

What did your pet eat? *

Do you have any special feeding instructions for your pet?

Please list all the medications and the instructions for each

If your pet needs to be sedated, do we have permission to do so? *

Yes
No

If yes please understand that by signing this form you understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. I hereby authorize the use of anesthetics, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read and fully understand this consent. The fees associated with these services have been explained to me, and I agree to pay such fees in full at the time my pet is released from the hospital.

I understand that if my pet is found to have fleas, we have the right to treat at your expense. *

I have read and understand

Please list all leashes/carriers/blankets/toys/food that is being left with your pet

Signature *

Date *

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