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Client ID

Client Name

Address

City

State

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Email

Phone

Patient ID

Pet Name

Species

Breed

Sex

Color

notes

We are very pleased that you have entrusted us with the care of your pet(s) while you are away. The following information will help to ensure everything is in order for his/her stay.

Please provide a phone number where you can be reached while you are gone

Secondary number or other emergency contact phone number

What DATE and TIME do you plan on picking up your pet from boarding?

Did you bring your pet's food from home?

Kennel food (Hill's I/D Lowfat canine or feline) will be provided if your pet runs out of their regular food.

If Yes, what type?

Feeding Instructions

May we sedate your pet if necessary for medical treatment?

The cost of sedation is $65/cat and $91/dog (plus $50 Preanesthetic Exam if needed).

Yes
No
Contact me first

Does your pet suffer from storm, firework or other noise phobias?

If needed, would you like us to administer calming medications during their stay?

Approximate cost for medication will be $15.00 - $25.00.

Yes
No
Contact me first

Please list any medication(s) and/or supplements, as well as instructions, that you brought for your pet

All medication needs to be in the original container.

Has your pet had these medication(s) today?

Which one(s)?

At what time?

Do you need any medication refills, including heartworm, flea, tick?

If so, which medications do you need refilled?

Please list any personal items (treats, toys, bedding) you brought with your pet.

PERSONAL ITEMS: Clean bedding will be provided for all pets boarding with us. BROOKSTONE ANIMAL HOSPITAL IS NOT RESPONSIBLE FOR DAMAGED OR LOST PERSONAL ITEMS LEFT WITH PETS.

Does your pet have a history of chewing up blankets/towels?

Is your dog aggressive with food, toys, other dogs, or people?

If Yes, Please explain

May we use your animal's picture on our website and/or in our social media sites?

Would you like your dog(s) bathed on the last day of boarding?

If you pet is receiving a bath, would you like us to apply cologne? (Free of Charge)

If your pet is receiving a bath, would you like your pet to have a bandana? (Free of Charge)

notes_3

Dogs will receive a free bath after 5 nights of boarding, with the exception of holidays and blackout dates for school breaks. Only one pet will receive a free bath if sharing a suite. If your pet is receiving a bath, please pick up after 12:00 pm.

PLEASE NOTE: If your pet has to be bathed due to messiness, we do charge a clean up bath fee. Clean up baths are $12 per bath.

Please list any other services you would like your pet to receive while boarding.

Extra Walk Daily - $13 per day
Personal Playtime (10 minutes) - $13 per day
Nail Trim - $24 (free if getting a bath)

Is your pet experiencing any problems you would like the doctor to examine? If so, What are they?

*please note you will be charged an exam fee for this service

notes_4

Answer these questions if your pet is receiving vaccines or being seen for a medical issue.

Has your pet ever had a vaccine reaction?

Any coughing/sneezing/vomiting/diarrhea? If so, for how long?

Has your pet been drinking more water or urinating more frequently? If so, for how long?

Does your cat go outside?

Do you take your dog swimming, on hikes, or in the woods?

note_5

Requirements For Boarding

1. All animals must be up to date on vaccines required for boarding (Dog - Distemper, Rabies, Bordetella) **We strongly recommend the Canine Influenza vaccine while boarding.**; (Cat - FVRCP, Rabies)

2. All animals must be free of external parasites (ie. ticks, fleas, etc.), or they will be treated at owner's expense.

3. All animals must have a negative fecal exam within the last 6 months.

4. In case of emergency, illness or injury, the doctors of Brookstone Animal Hospital have my permission to treat, prescribe for, or perform surgical procedures upon my pet(s) while they are boarding at Brookstone Animal Hospital. There will be an exam fee associated with this service along with cost of treatment. We will make all attempts necessary to contact you should any problem with your pet(s) arise.

I have read the boarding requirements and understand the hospital's policies

I accept.

Today's Date

notes_6

Consent for CPR While Boarding

If a life-threatening complications such as respiratory and/or cardiac arrest occur while my pet is boarding, the staff at Brookstone Animal Hospital can perform cardiopulmonary resuscitation (CPR) . If my pet stops breathing or its heart stops beating, I realize even the most successful CPR may not restore him/her to good mental and physical health. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. In spite of the limited likelihood of success from CPR treatment, I accept that such care brings with it considerable expense.

By initialing one of the following choices, I hereby request:

Yes, perform CPR on my pet if doctor deems necessary (~$100 service charge)
No, do not attempt to resuscitate my pet

notes_7

I accept that if hospital staff members are unable to reach me within 20 minutes after the initiation of CPR, and after administering reasonable treatment and there appears to be virtually no hope for medical success, CPR will be withdrawn and my pet will be humanely euthanized. I am providing the hospital with phone numbers (listed above on theis form) at which I can be reached in the event of a decline in his/her condition.

I understand the cost of the medical services discussed with me and agree to make satisfactory arrangements to cover all outstanding veterinary fees at the time my pet is either discharged from the hospital, transferred to another facility, dies or is humanely euthanized.

Signature of Owner or Authorized Agent

Today's Date