Boarding Consent Form

Document Sample
Boarding Consent Form Powered By Docstoc
					               Animal Hospital of Lynnfield
                                     Boarding Consent Form


Pet’s Name: ______________________

Date & Time In: _______________________           Date & Time Out:_______________________

Client Name: ____________________________________________________________________

       Please give ALL Phone Numbers where you can be reached:

       (       )_____________________________ (            )_______________________________

       (       )_____________________________(             )_______________________________

       Email _____________________________________________________________________

       Other Emergency Contact: ____________________________________________________
       This person is authorized by you to make any and all medical decisions in your absence.

Medications and Instructions:                                                ________________

Morning: _________________________________________________________________________

Evening: _________________________________________________________________________

Other: ___________________________________________________________________________

What medications has your pet had TODAY? __________________________________________

_________________________________________________________________________________

What time was it given?_____________________________________________________________

Did you bring your pet’s own food? _____No _____Yes If yes, what kind/how much did you
bring? __________________________________________________________________________
If not and your pet is on a special diet, an applicable fee will apply.

Has your pet eaten yet today? _____No _____Yes       If yes, when? _______________________

What time does your pet need to be fed next? _________________________________________

Note feeding instructions, how much and when:

Morning: ___________________________             Evening: ______________________________

Other: __________________________________________________________________________


1/31/2013 2:37 PM                  Boarding Consent Form                   Page 1 of 2
               Animal Hospital of Lynnfield
                                         Boarding Consent Form



Are there any particular problems that you would like to have a doctor address i.e. recheck ears, express anal
glands, etc.? An examination fee will apply.


Would you like your dog bathed before going home?         _____ Yes     _____ No

Please be aware that this is not a full grooming visit and is not recommended for an already matted coat.
Therefore, we will not bathe your dog if routine grooming has not been maintained.

Note: Should other procedures (skin scraping for mites, ear smear, stool samples, etc.) be deemed necessary in
the attending veterinarian’s professional medical judgment, we will attempt to reach you for permission to
perform these procedures, but will proceed if unable to reach you or your authorized agent. If I cannot be
reached, I authorize unforeseen, non-emergency procedures and understand and agree to pay for such
procedures.

I understand that my pet may be given a calming agent to relax him/her while boarding if deemed
necessary and accept financial responsibility for this charge. Initial________________________

NOTE: Because we are a full service animal hospital dedicated to the safety and well being of all our
patients, animals under our care will be made current on all vaccines and preventative care (Rabies,
distemper, canine bordetella, canine heartworm and tick borne disease testing, fecal tests, heartworm
and flea and tick preventatives). If your pet enters the hospital with fleas or ticks, treatment will be
administered. Additional fees will apply.

        I am the owner, responsible agent for, or authorized agent of this animal. I understand the nature of the
procedure(s), that there are risks involved with any surgery or procedure, and that results cannot be guaranteed.
I authorize the veterinarians and staff of Animal Hospital of Lynnfield to perform all procedures as set forth
above, including surgery, medical services, treatment, laboratory tests, x-rays, medications, and anesthetics.
Further, in case of emergency or unexpected illness while boarding, I consent to any necessary procedure not
set forth on this form, should that procedure be necessary and desirable in the attending veterinarian’s
professional medical opinion. I understand that The Animal Hospital of Lynnfield will attempt to contact me via
the methods I have given and that an attendant is not on hospital premises 24 hours per day and that after hours
care is provided as necessary in the judgement of the veterinarian in charge. I consent to the release of medical
information.


     I HAVE RECEIVED AN ESTIMATE AND AGREE TO PAY IN FULL FOR SERVICES PERFORMED
INCLUDING THOSE DEEMED NECESSARY FOR MEDICAL OR SURGICAL COMPLICATIONS OR
UNFORESEEN ILLNESSES OR OTHER CIRCUMSTANCES.


Signature:                                                         Date:


1/31/2013 2:37 PM                      Boarding Consent Form                     Page 2 of 2

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:0
posted:1/31/2013
language:English
pages:2