DIABETIC BOARDING ADMISSION FORM

DIABETIC BOARDING ADMISSION FORM
Client Name:*

First NameLast Name
Patient Name:*
Breed:*
Color/Markings:*
Age:*
Please include a descriptor (years, months, weeks)
I understand that my diabetic pet is a HOSPITALIZED BOARDER and will be under the care of a doctor, who along with the veterinary staff, will monitor my pet’s needs daily. I understand that the fee for diabetic boarding includes the night of boarding, a daily doctor examination, medication administration fees, and a minimum of one glucose test daily. If my pet is not eating a doctor may add on a appetite stimulant. I understand that I will be responsible for any medications that are added on during my pets stay.
Initial:*

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In the event that my pet’s diabetic needs change while boarding (for example: decreased appetite, unfamiliar environmental induced stress, etc) one of the staff veterinarians at Waverly Animal Hospital will promptly treat my pet’s acute medical condition (with any additional fees added to my invoice), then attempt to notify me of my pet’s status, and to make me aware of the changes in my invoice. I will leave a phone number below where the attending veterinarian can directly contact me.
Initial:*

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Failure to complete this form for each boarding stay prevents us from treating your pet appropriately. Please do not leave any question below unanswered. Syringes and insulin can be provided at an additional cost, if neccessary.
Initial:*

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Emergency phone number(s)*
Be sure to include area code(s)!
INSULIN INFORMATION:
Type of Insulin:*
Vetsulin (Caninsulin), NPH (Humulin N), Lente (Humulin L), Ultralente (Humulin U), PZI, Lantus, or Other
Frequency:*
Number of Units given each time:*
What time do you normally give the insulin?*
BE SURE TO SPECIFY AM/PM
Did you bring your insulin? *
Did you bring you own syringes?*
What size syringes do you use?*
Was insulin given today?*
What time was the last dose?*
Do you need a refill of Insulin?*
Do you need a refill of syringes?*
FOOD INFORMATION:
How often is your pet fed?*
(Once Daily, Twice Daily, Three times Daily, Free Fed, etc)
What food does your pet eat?*
Include both wet & dry varieties
How much do you feed at each feeding?*
Please use the standard 8oz = cup
When was the last time your pet ate a full meal?*
Please include date and time (including AM/PM).
HABITS INFORMATION:
Has your pet shown a change in drinking frequency?*
Has your pet shown a change in drinking amount?*
Has your pet shown a change in eating habits?*
Has your pet shown a change in weight?*
If Waverly Animal Hospital is not your regular veterinarian, do you have a relationship with a veterinarian that is monitoring and managing your pet's diabetes?
I have read and agree with the above statements.
Signed,*

Clear
Should be Empty:

DIABETIC BOARDING ADMISSION FORM

INSULIN INFORMATION:

FOOD INFORMATION:

HABITS INFORMATION: