Pet Boarding Form Boston Heights

1
Please fill out for your pet each time they board with us. If boarding more than one pet, please submit a separate form for each pet.
2
Owner's Name* This field is required.
First Name
Last Name
3
Pet's Name* This field is required.
Pet's Name
Owner's Last Name
4
E-mail* This field is required.
5
Emergency Phone Number (where we can reach you while you are away)* This field is required.
Area Code
Phone Number
6
Secondary Emergency Contact Name (not required)
First Name
Last Name
7
Secondary Emergency Phone Number (where we can reach you while you are away)
Area Code
Phone Number
8
Arrival Date * This field is required.
9
Departure Date* This field is required.
10
Are you bringing any of the following for your pet? Mark all that apply. Please note, we take all reasonable care of personal items for your pet; however we cannot be held responsible for loss or damage.
Crate/Carrier
Food
Medication
Pet Bed
Blanket
Toys
11
Please describe crate/carrier color and style. Please label when possible. Example: Blue pet carrier with black door. * This field is required.
12
Please describe food - list brand and packaging. Please label with your pet's name. Example: Iams small breed puppy formula; 3 baggies.* This field is required.
13
Please describe your pet's blanket. Please label with your pet's name. Example: Red fleece OSU blanket.* This field is required.
14
Please describe your pet's bed. Please label with your pet's name. Example: Blue rectangle bed with tan fleece.* This field is required.
15
Please describe your pet's toys individually. Please label each toy with your pet's name. Example: Large red kong, yellow plush monkey, white nylabone.* This field is required.
16
How many medications are we administering to your pet while they are staying with us?* This field is required.
1
2
3
4
5
6
None
17
Please list the name and dose of the first medication. Example: Rimadyl 75 mg, 1/2 tablet.* This field is required.
18
When & how often should we administer the first medication? Check all that apply.* This field is required.
AM
Noon
PM
Every day
Every other day
One time only
As needed
Other
19
Please list any special instructions for the first medication dosing schedule.
20
Please choose the appropriate administration method for the first medication.* This field is required.
Oral
Topical
Eyes
Ears
21
Please list any special instructions for dosing your pet's first medication. Example: Give in cheese, pill pocket, peanut butter, food, etc.
22
Has your pet had this first medication yet today?* This field is required.
yes
no
23
Please list the name and dose of the second medication.* This field is required.
24
When & how often should we administer the second medication? Check all that apply.* This field is required.
AM
Noon
PM
Every day
Every other day
One time only
As needed
Other
25
Please list any special instructions for the second medication dosing schedule.
26
Please choose the appropriate administration method for the second medication.* This field is required.
Oral
Topical
Eyes
Ears
27
Please list any special instructions for dosing your pet's second medication. Example: Give in cheese, pill pocket, peanut butter, food, etc.
28
Has your pet had this second medication yet today?* This field is required.
29
Please list the name and dose of the third medication.* This field is required.
30
When & how often should we administer the third medication? Check all that apply.* This field is required.
AM
Noon
PM
Every day
Every other day
One time only
As needed
Other
31
Please list any special instructions for the third medication dosing schedule.
32
Please choose the appropriate administration method for the third medication.* This field is required.
Oral
Topical
Eyes
Ears
33
Please list any special instructions for dosing your pet's third medication. Example: Give in cheese, pill pocket, peanut butter, food, etc.
34
Has your pet had this third medication yet today?* This field is required.
35
Please list the name and dose of the fourth medication.* This field is required.
36
When & how often should we administer the fourth medication? Check all that apply.* This field is required.
AM
Noon
PM
Every day
Every other day
One time only
As needed
Other
37
Please list any special instructions for the fourth medication dosing schedule.
38
Please choose the appropriate administration method for the fourth medication.* This field is required.
Oral
Topical
Eyes
Ears
39
Please list any special instructions for dosing your pet's fourth medication. Example: Give in cheese, pill pocket, peanut butter, food, etc.
40
Has your pet had this fourth medication yet today?* This field is required.
41
Please list the name and dose of the fifth medication.* This field is required.
42
When & how often should we administer the fifth medication? Check all that apply.* This field is required.
AM
Noon
PM
Every day
Every other day
One time only
As needed
Other
43
Please list any special instructions for the fifth medication dosing schedule.
44
Please choose the appropriate administration method for the fifth medication.* This field is required.
Oral
Topical
Eyes
Ears
45
Please list any special instructions for dosing your pet's fifth medication. Example: Give in cheese, pill pocket, peanut butter, food, etc.
46
Has your pet had this fifth medication yet today?* This field is required.
47
Please list the name and dose of the sixth medication. For any additional medications, please describe below.* This field is required.
48
When & how often should we administer the sixth medication? Check all that apply.* This field is required.
AM
Noon
PM
Every day
Every other day
One time only
As needed
Other
49
Please list any special instructions for the sixth/additional medication dosing schedule.
50
Please choose the appropriate administration method for the sixth medication.* This field is required.
Oral
Topical
Eyes
Ears
51
Please list any special instructions for dosing your pet's sixth medication. Example: Give in cheese, pill pocket, peanut butter, food, etc.
52
Has your pet had this sixth medication yet today?* This field is required.
53
Feeding/Diet Instructions:* This field is required.
Feed Own Food
Feed Kennel Diet
54
How often should we feed your pet?* This field is required.
Once per day
Twice per day
Three times per day
Other
55
Please list any special situations that require additional meals during the day. * This field is required.
56
How much food should we feed per meal? Example: Feed 1/2 cup dry kibble plus 1 can mixed together per meal.* This field is required.
57
Was your pet fed today (drop off day)?* This field is required.
Yes
No
58
Is your pet allowed to have treats?* This field is required.
Yes, any treats are ok
Yes, but with restrictions
No, do not feed any treats
59
Please list any treat restrictions. Example: Please only feed 2 treats after dinner.* This field is required.
60
Has your pet ever shown aggression toward people or other animals?* This field is required.
No
Yes
61
If yes, please explain:* This field is required.
62
Please indicate your preference in the event of a medical problem or emergency:* This field is required.
Treat as needed (no phone contact required before treatment)
Contact me prior to treatment for SERIOUS medical problems only
Contact me prior to any medical treatment
63
In case of illness or injury, I, the undersigned, to hereby give my consent for the doctors of Boston Heights Veterinary Hospital to treat, prescribe, or operate on my pet named above. They are to use all reasonable precautions against illness, injury, or escape of my pet, but they will not be held liable or responsible in any manner what so ever, under any circumstances, on account of the care, treatment, or safe keeping of my pet, as it is thoroughly understood that I assume all risks. Should the circumstance arise that my pet remains unclaimed after the date which I have stated as the pick-up date, I understand that written notice will be mailed to the address on file. Seven days after I understand that such action will not relieve me from paying all costs of your service and the use of your hospital, including the cost of the boarding service. Please type your name to electronically sign this form.* This field is required.
First Name
Last Name
64
Please verify that you are human* This field is required.
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