Medical Boarding Request Form Disclaimer: Filling out this form does not guarantee a medical boarding reservation. Please call the office to schedule: (610) 880-3534 "*" indicates required fields X/TwitterThis field is for validation purposes and should be left unchanged.Client & PetClient's Name* First Last Owner's E-mail Address* Pet's Name*DatesArrival Date MM slash DD slash YYYY Expected Departure Date MM slash DD slash YYYY MedicationsMedications: Please type out the Medication names, Strength (mg, ml, etc), Directions (Must Match Bottle), and Last Dose (Day/Time).*If medications are not in hospital-dispensed bottles or labels do not match the description, we may not be able to medicate your pet. Please pay special attention to this for the safety of your pet!*FeedingFeeding Schedule: (Please choose an option based on the below questions) HVH Brand (Hill's Science Diet) Dry / Canned Owner food *If not feeding HVH brand or Owner Food, list what brand of food:Food Frequency: (How often: Once or Twice daily and How much food is given at each meal?)We provide all bedding, bowls, etc. We recommend you do not leave personal items at the hospital; items can be misplaced. Keep leashes and collars with you.AS THE OWNER YOU ARE RESPONSIBLE for ensuring all property is returned to you at discharge.Client Signature*Services While BoardingWe would like the following services for our pet while boarding: Pedicure Bath Other… Enter other…Special ConcernsSignature of Owner*Date MM slash DD slash YYYY Boarding Permissions AgreementMedical Authorization (Please Sign below):HICKORY VETERINARY AND SPECIALTY HOSPITAL IS AUTHORIZED TO RENDER MEDICAL TREATMENT FOR ILLNESS OR INJURY as deemed necessary by the doctors while boarding. If not life-threatening, we will call before treatment. If no call back within 2 hours after a message, doctors are authorized to perform exam and necessary care. All costs are due at pick-up.Signature*Emergency Medical CareEMERGENCY MEDICAL CARE: Should unexpected life-saving emergency care be required, I authorize:* EMERGENCY RESUSCITATION and I agree to any cost incurred ($750 or more). Hickory Veterinary and Specialty Hospital does NOT have permission to provide emergency resuscitation. Health & BehaviorPLEASE ANSWER THE FOLLOWING QUESTIONS:Does your pet have any current medical conditions? If yes, please elaborate.Does your pet have any allergies? If yes, please elaborate.Does your pet have behavior challenges/needs? If yes, please elaborate.Is your pet on behavioral medication? If yes, please elaborate.Has your pet ever bitten anyone? If yes, please elaborate.Special Requests & PoliciesIf you have any special circumstances or requests, we will try to accommodate. Examples include diet (house food is Science Diet), extra exercise, or medications. For medical services (vaccines, check lumps, ears, legs, teeth, etc.) the owner must authorize. Exam fee of $85.ABANDONMENT OF ANIMALS: If the client does not pick up or call within 3 days after the agreed upon pick up date, a certified letter will be sent. If the pet is not claimed and fees paid within the specified time, the client relinquishes all rights; the animal becomes property of Hickory Veterinary Hospital.VACCINATIONS REQUIRED TO BOARD: Dogs: Rabies, Distemper, Parvovirus, Bordetella, Canine Influenza. Cats: Rabies and FVRCP. Provide proof at least 1 week before boarding. If required, we can schedule vaccines. An up-to-date wellness exam with our doctors is required to board (if not our client, $72).Photo PermissionPermission to use photos of your pet on our website, social media, etc:* Yes No This form expires 1 year from the date signed.Signature of Owner or Agent*ContactsPhone number of Primary Contact*Date MM slash DD slash YYYY Alternate ContactPhone number of Secondary ContactOwner/Authorized RepresentativeDate MM slash DD slash YYYY
