Form - Companion

1
Drop Off Date* This field is required.
Date
Year
Month
Day
2
Pick up Date* This field is required.
Date
Year
Month
Day
3
Owner Name* This field is required.
First Name
Last Name
4
Pet Name* This field is required.
5
Feeding Instructions* This field is required.
Yes
Please Select
Yes
No
Did you bring your pet's food?
When did your pet last eat?
Cups of wet food per meal?
Cups of dry food per meal?
Times/Day Wet
Times/Day Dry
6
Additional Feeding Information
Huge
Large
Normal
Small
Ok
Ok
7
Medications* This field is required.Please list all medications & dosages (Amount & times/day) your pet needs to receive while boarding ****All Medication should be in original bottles to ensure correct dosing****
Huge
Large
Normal
Small
Ok
Ok
8
I understand that if my pet is due for any required boarding vaccines, the vaccines will be administered to my pet upon arrival.* This field is required.
YESNO
9
Will your pet require any additional services (exam, vaccines) during their stay?* This field is required.
YESNO
10
Please Elaborate:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
Medical Conditions* This field is required.Please list any medical conditions or history of which we should be aware of while your pet is boarding with us. (i.e. orthopedic problems, back problems, food allergies, etc.) *NOT TO BE TREATED UNLESS WORSENS*
Huge
Large
Normal
Small
Ok
Ok
12
Will you be boarding another pet?
YESNO
13
Pet #2 Name* This field is required.
14
Feeding Instructions for Pet #2
Yes
Please Select
Yes
No
Did you bring your pet's food?
When did your pet last eat?
Cups of wet food per meal?
Cups of dry food per meal?
Times/Day Wet
Times/Day Dry
15
Additional Feeding Information for Pet #2
Huge
Large
Normal
Small
Ok
Ok
16
Medications for Pet #2* This field is required.Please list all medications & dosages (Amount & times/day) your pet needs to receive while boarding ****All Medication should be in original bottles to ensure correct dosing****
Huge
Large
Normal
Small
Ok
Ok
17
I understand that if my pet is due for any required boarding vaccines, the vaccines will be administered to my pet upon arrival.* This field is required.
YESNO
18
Will your pet require any additional services (exam, vaccines) during their stay?* This field is required.
YESNO
19
Please Elaborate:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
20
Medical Conditions for Pet #2* This field is required.Please list any medical conditions or history of which we should be aware of while your pet is boarding with us. (i.e. orthopedic problems, back problems, food allergies, etc.) *NOT TO BE TREATED UNLESS WORSENS*
Huge
Large
Normal
Small
Ok
Ok
21
I would like to be called PRIOR to treatment conditions discovered while boarding* This field is required.
YESNO
22
I would like to be called AFTER treatment conditions discovered while boarding* This field is required.
YESNO
23
Nail Trim?* This field is required.
YESNO
24
Anal Glands?* This field is required.
YESNO
25
Other Service?
26
Would you like your pet to have an additional walk or playtime?* This field is required.
YESNO
27
How many walks or playtimes?
Please enter number of additional walks
Please enter number of additional playtimes
28
Would you like your pet to receive a bath?* This field is required.
YESNO
29
Has your pet bitten anyone? * This field is required.
YESNO
30
May we put bedding in with your pet? * This field is required.We are not responsible if your pet ingests any foreign materials. We will monitor and remove items if we see problems
YESNO
31
Personal Belongings* This field is required.Please list all personal belongings you are leaving with your pet. *We try to ensure all belongings are returned to you, however we do not guarantee against loss or damage*
Huge
Large
Normal
Small
Ok
Ok
32
Phone Numbers
Please enter your phone
Please enter your phone
Please enter your phone
33
Emergency Contact
Contact Name
Contact Phone
34
Does this person have your permission to authorize medical treatment for which you will be financially responsible?* This field is required.
YESNO
35
**If no one can be reached to make an emergency decision on my pet’s behalf, I authorize Companion Animal Clinic Doctors to make decisions based on my pet’s best interest.**

**I will be financially responsible for all fees incurred for treatment and care of my pet(s) including consulting veterinary specialists.**

**Pets that are infested with fleas or those that are unusually dirty will be bathed, and I understand that these services will be charged and must be paid at the release of my pet.**
36
Today's Date* This field is required.
Date
Year
Month
Day
37
Owner Signature* This field is required.
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