Outpatient Admission Form (Boarding/Grooming/Surgery Consent Form)

Owner Name

First Name Last Name

Pet Name

Reason for today's visit:

* If your pet is having a surgical procedure, please fill out the surgical and anesthesia consent form as well*

Best contact number to reach you:

Area Code Phone Number

Secondary contact number:

Area Code Phone Number

If your pet is boarding - What date are you picking up your pet?

Date

If your dog is boarding with us, would you like for them to receive a bath and a nail trim before going home? There is an additional charge for this service that is dependent on your dog's weight. (We will do the bath the morning of your scheduled pick up. If you choose to have your dog bathed, pick up time is AFTER 3pm. )

yes no

*Please note- grooming must be scheduled ahead of time with our groomer*

If grooming, please indicate preferences: (example: same haircut as usual, please cut hair shorter than last time, etc)

Feeding instructions: How often and how much do you typically feed your pet? (for example: 1 cup of dry food, twice a day) Does your pet have any food allergies or a special diet?

Medications: Please list all medications your pet is currently taking, including strength, quantity, and frequency. (for example: Apoquel 16mg- 1 tablet twice a day) :

Does your pet need any vaccinations or routine testing while they are here? We require all patients have current vaccinations if they are staying in our hospital or boarding facility. If you are unsure if your pet's vaccinations are due, we will inform you upon check-in. The required vaccines for dogs are DHPP, Rabies, and Bordetella. The required vaccines for cats are FVRCP and Rabies.

DHPP (Distemper combo for dogs) Rabies (dogs and cats) Bordetella (dogs) Leptospirosis (dogs) Lyme (dogs) Influenza (dogs) Heartworm test (dogs) FVRCP (Distemper combo for cats) Feline Leukemia (cats)

If your pet is having an exam with a doctor, please provide a short description of any concerns or symptoms. (example: vomiting, diarrhea, change in eating or drinking, lethargy, etc)

Would you like any additional services while your pet is here?

Nail Trim Anal Gland Expression Ear Cleaning Microchip

Your pet will be checked for fleas while in the hospital. If fleas are noted, a fast acting flea treatment will be administered for the safety of your pet and the other pets in hospital. The cost of the treatment will be added to your invoice.
If you are dropping your pet off for an exam, please be advised that the veterinarian will see your pet at their earliest convenience between scheduled appointments and surgeries and will contact you after the exam.
If hospitalization is needed, please be aware a deposit may be required prior to admittance and the balance will be due at the time of discharge. If you have financial concerns, please discuss them with the receptionist, technician, or doctor prior to authorizing care.
I understand that fees are due at discharge and that no guarantee or warranty can ethically or professionally be made regarding results or cure.
I understand that Suburban Animal Hospital cannot guarantee the return of any personal items left with my pet.
All pets must be current on all required vaccinations. If vaccinations were updated elsewhere, written proof is required at check in or we will update the vaccinations here.
Please note that we do not have overnight staffing.
I have read and fully understand the terms and conditions set forth in this document and am aware that it will apply to future visits as well.
I, the undersigned owner or agent of the pet named above, certify that I am 18 years of age or older and authorize the veterinarian of Suburban Animal Hospital to treat or perform needed procedures on my pet.
In the event of a medical emergency, if I cannot be reached, I assume responsibility for any necessary diagnostics and treatments, unless expressly stated otherwise.

Life sustaining efforts directive: In the unlikely event of cardiac or respiratory arrest it is our policy to always attempt resuscitation (CPR) unless "Do Not Resuscitate" (DNR) is selected. You will be responsible for the additional costs associated with CPR. Please select CPR or DNR.

CPR DNR

Signature of Owner:

Clear

Date:

Date

Suburban Animal Hospital