MEDICATION ADMINISTRATION FORM FOR HOSPITALIZED AND BOARDING PATIENTS

COMPLETE THE TABLE BELOW FOR NON-TAPER MEDICATIONS. IF YOU RUN OUT OF SPACE, GO TO THE NEXT QUESTION.*

	DRUG NAME & STRENGTH	DIRECTIONS	DESCRIPTION	LAST GIVEN DATE & TIME	NEXT DOSE DUE DATE & TIME	CONTAINER (Original Vial, Ziplock bag, pill organizer, etc)	REFILL NEEDED? IF YES, HOW MANY DAYS?
DRUG #1
DRUG #2
DRUG #3
DRUG #4

IS YOUR PET ON OTHER NON-TAPER MEDICATIONS? IF SO, PLEASE LIST THE DRUG NAME, STRENGTH, DIRECTIONS, DESCRIPTIONS, LAST GIVEN DATE & TIME, NEXT DOSE DATE & TIME, CONTAINER DESCRIPTION, AND IF A REFILL IS NEEDED HOW MANY DAYS YOU WOULD LIKE.
Please write in continuous sentences - do not hit enter to start a new line.
PLEASE DESCRIBE ANY TAPER MEDICATIONS YOUR PET IS CURRENTLY ON. INCLUDE HOW MANY DAYS IT HAS BEEN ON EACH DIRECTION. Ex: PREDNISONE 5MG, white round tablet, has been taking 1 tab twice daily for three days, last dose given 8/28 7pm, next dose due 8/29 7am, in original container, no refill needed.
Please write in continuous sentences - do not hit enter to start a new line.
Please read the following terms and conditions regarding medication administration.
1. Our scheduled times for medication administration are: 7am, 12pm, 4pm, 7pm and 11pm. Each time a technician has to administer medications there will be a $7.00 charge (regardless of the quantity of medications given at that time).
2. Medications can not be placed in food bags.
3. If your pet is on medications during their stay and sharing with another pet, we may need to separate them for their stay if we are unsuccessful at giving the medications. The charges will be adjusted accordingly.
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