Shaffer Animal Hospital - Daycare Emergency Info

1
Emergency Contact Name
Emergency Telephone Number
Email
2
In the event of a Medical Emergency we will refer your pet to Shaffer Animal Hospital. We will then contact you so you are informed of your pet’s well-being.
Initial
3
In the event of a Medical Emergency we will refer your pet to Shaffer Animal Hospital. We will then contact you so you are informed of your pet’s well-being.
Initial
4
Non-Emergency Medical Concern, if we noticed an non-emergency, incidental medical concerns while your pet is staying with us, do you wish to refer it to the on site Animal Hospital or your vet?
Initial
5
Please initial acknowledgement. There will be an incidental charge for the transportation of your pet to an offsite location.
Initial
6
Do you wish to be contacted regarding any treatment
Prior to treatment
Directly after Treatment
Upon your return
7
Please Select
Please Select
Yes
No
Are you providing your pet’s food during their stay?
What do you feed your pet?
How often do you feed your pet?
How much do you feed your pet?
Please Select
Please Select
Yes
No
Does your pet have storm anxiety?
Will you be providing medication for storm anxiety?
8
Does your pet have any ongoing medical concerns, or is there any medical history we should be aware of?
Yes
No
9
If yes, please specify
10
Is your pet on any medications?
Yes
No
11
List Medications and Directions
12
Signature* This field is required.
Clear
13
Date* This field is required.
Date
Year
Month
Day
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