Boarding Treatment Amendment

1

Your Name:* This field is required.

First Name

Last Name

2

Your E-Mail Address* This field is required.

example@example.com

3

Your Pet's Name* This field is required.

4

Date of Check-In:* This field is required.

Date

5

Which instructions do you need to amend?* This field is required.

Feeding Instructions

Medication Instructions

Both

6

First Medication to be modified - Name:* This field is required.

7

First Medication to be modified - Strength:* This field is required.

(ex: 50mg; 0.4mg)

8

First Medication to be modified - Quantity to give per dose:* This field is required.

(ex: 1 capsule; 1/2 tablet; 20 units)

9

First Medication to be modified - Frequency of Administration* This field is required.

Every 24 Hours (Once a day)

Every 12 Hours (Twice a day)

Every 8 Hours (Three times a day)

Every Other Day (Specify date to begin administering in the Special Instructions field on the next page)

Once On A Specific Date (Specify date in the Special Instructions field on the next page)

Administer Only As Needed (Specify directions in the Special Instructions field on the next page)

10

First Medication to be modified - Time(s) of Administration

First Dose

Second Dose (if applicable)

Third Dose (if applicable)

Special Instructions

11

Do you have another medication or supplement to modify?* This field is required.

Yes

No

12

Second Medication to be modified - Name:* This field is required.

13

Second Medication to be modified - Strength:* This field is required.

(ex: 50mg; 0.4mg)

14

Second Medication to be modified - Quantity to give per dose:* This field is required.

(ex: 1 capsule; 1/2 tablet; 20 units)

15

Second Medication to be modified - Frequency of Administration* This field is required.

Every 24 Hours (Once a day)

Every 12 Hours (Twice a day)

Every 8 Hours (Three times a day)

Every Other Day (Specify date to begin administering in the Special Instructions field on the next page)

Once On A Specific Date (Specify date in the Special Instructions field on the next page)

Administer Only As Needed (Specify directions in the Special Instructions field on the next page)

16

Second Medication to be modified - Time(s) of Administration

First Dose

Second Dose (if applicable)

Third Dose (if applicable)

Special Instructions

17

Do you have another medication or supplement to modify?* This field is required.

Yes

No

18

Third Medication to be modified - Name:* This field is required.

19

Third Medication to be modified - Strength:* This field is required.

(ex: 50mg; 0.4mg)

20

Third Medication to be modified - Quantity to give per dose:* This field is required.

(ex: 1 capsule; 1/2 tablet; 20 units)

21

Third Medication to be modified - Frequency of Administration* This field is required.

Every 24 Hours (Once a day)

Every 12 Hours (Twice a day)

Every 8 Hours (Three times a day)

Every Other Day (Specify date to begin administering in the Special Instructions field on the next page)

Once On A Specific Date (Specify date in the Special Instructions field on the next page)

Administer Only As Needed (Specify directions in the Special Instructions field on the next page)

22

Third Medication to be modified - Time(s) of Administration

First Dose

Second Dose (if applicable)

Third Dose (if applicable)

Special Instructions

23

Do you have another medication or supplement to modify?* This field is required.

Yes

No

24

Fourth Medication to be modified - Name:* This field is required.

25

Fourth Medication to be modified - Strength:* This field is required.

(ex: 50mg; 0.4mg)

26

Fourth Medication to be modified - Quantity to give per dose:* This field is required.

(ex: 1 capsule; 1/2 tablet; 20 units)

27

Fourth Medication to be modified - Frequency of Administration* This field is required.

Every 24 Hours (Once a day)

Every 12 Hours (Twice a day)

Every 8 Hours (Three times a day)

Every Other Day (Specify date to begin administering in the Special Instructions field on the next page)

Once On A Specific Date (Specify date in the Special Instructions field on the next page)

Administer Only As Needed (Specify directions in the Special Instructions field on the next page)

28

Fourth Medication to be modified - Time(s) of Administration

First Dose

Second Dose (if applicable)

Third Dose (if applicable)

Special Instructions

29

Do you have another medication or supplement to modify?* This field is required.

Yes

No

30

Fifth Medication to be modified - Name:* This field is required.

31

Fifth Medication to be modified - Strength:* This field is required.

(ex: 50mg; 0.4mg)

32

Fifth Medication to be modified - Quantity to give per dose:* This field is required.

(ex: 1 capsule; 1/2 tablet; 20 units)

33

Fifth Medication to be modified - Frequency of Administration* This field is required.

Every 24 Hours (Once a day)

Every 12 Hours (Twice a day)

Every 8 Hours (Three times a day)

Every Other Day (Specify date to begin administering in the Special Instructions field on the next page)

Once On A Specific Date (Specify date in the Special Instructions field on the next page)

Administer Only As Needed (Specify directions in the Special Instructions field on the next page)

34

Fifth Medication to be modified - Time(s) of Administration

First Dose

Second Dose (if applicable)

Third Dose (if applicable)

Special Instructions

35

Do you have another medication or supplement to modify?* This field is required.

Yes

No

36

Sixth Medication to be modified - Name:* This field is required.

37

Sixth Medication to be modified - Strength:* This field is required.

(ex: 50mg; 0.4mg)

38

Sixth Medication to be modified - Quantity to give per dose:* This field is required.

(ex: 1 capsule; 1/2 tablet; 20 units)

39

Sixth Medication to be modified - Frequency of Administration* This field is required.

Every 24 Hours (Once a day)

Every 12 Hours (Twice a day)

Every 8 Hours (Three times a day)

Every Other Day (Specify date to begin administering in the Special Instructions field on the next page)

Once On A Specific Date (Specify date in the Special Instructions field on the next page)

Administer Only As Needed (Specify directions in the Special Instructions field on the next page)

40

Sixth Medication to be modified - Time(s) of Administration

First Dose

Second Dose (if applicable)

Third Dose (if applicable)

Special Instructions

41

Do you have another medication or supplement to modify?* This field is required.

Yes

No

42

Seventh Medication to be modified - Name:* This field is required.

43

Seventh Medication to be modified - Strength:* This field is required.

(ex: 50mg; 0.4mg)

44

Seventh Medication to be modified - Quantity to give per dose:* This field is required.

(ex: 1 capsule; 1/2 tablet; 20 units)

45

Seventh Medication to be modified - Frequency of Administration* This field is required.

Every 24 Hours (Once a day)

Every 12 Hours (Twice a day)

Every 8 Hours (Three times a day)

Every Other Day (Specify date to begin administering in the Special Instructions field on the next page)

Once On A Specific Date (Specify date in the Special Instructions field on the next page)

Administer Only As Needed (Specify directions in the Special Instructions field on the next page)

46

Seventh Medication to be modified - Time(s) of AdministrationPlease indicate the time of day that each dose should be administered. If the medication is only administered once or twice a day, choose "N/A - Not Applicable" for the remaining doses.

First Dose

Second Dose (if applicable)

Third Dose (if applicable)

Special Instructions

47

How many times per day does your pet eat?* This field is required.

Once a day

Twice a day

Leave food out all day

48

What time do you feed the first meal?* This field is required.

49

What type of food should be fed at the first meal?* This field is required.

Barnside provided Hill's Science Diet Dry Sensitive Stomach/Sensitive Skin

Food you are bringing from home in pre-portioned, individually bagged and labeled meals

Both Barnside Dry and Food from home

50

What are the feeding instructions for the food from home?* This field is required.

Feed one pre-portioned, individually bagged and labeled meal

Feed one pre-portioned, individually bagged and labeled meal with client provided canned food added (indicate amount of canned food in the special instructions section)

Add client provided canned food to the Barnside provided Hill's Sensitive Stomach/Sensitive Skin Dry food (indicate amount of canned food in the special instructions section)

51

Are there any special feeding instructions for the first meal?Please note that special feeding instructions requests cannot violate any Barnside policies or procedures and are subject to approval by the doctor on duty and/or Barnside management.

52

What time do you feed the second meal:* This field is required.

53

What type of food should be fed at the second meal?* This field is required.

Barnside provided Hill's Science Diet Dry Sensitive Stomach/Sensitive Skin

Food you are bringing from home in pre-portioned, individually bagged and labeled meals

Both Barnside Dry and Food from home

54

What are the feeding instructions for the food from home?* This field is required.

Feed one pre-portioned, individually bagged and labeled meal

Feed one pre-portioned, individually bagged and labeled meal with client provided canned food added (indicate amount of canned food in the special instructions section)

Add client provided canned food to the Barnside provided Hill's Sensitive Stomach/Sensitive Skin Dry food (indicate amount of canned food in the special instructions section)

55

Are there any special feeding instructions for the second meal?Please note that special feeding instructions requests cannot violate any Barnside policies or procedures and are subject to approval by the doctor on duty and/or Barnside management.