villagevethouston.com - Diabetic Boarding Consent Form

Diabetic Boarding Consent Form
Client Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Pet's Name:*
Age:*
Sex:*
Breed:*
Drop off date:*

MonthDayYear
Date
Pick up date and time:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Emergency Contact Name:*
Emergency Phone #:*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:*
YESNO
Insulin brand:
Current dosing:
units am/pm.
Time of last dose:
Other medication dosing:
Diet:
Feeding Instructions:
Any Special Instructions:
Due to the nature of your pet's diabetic needs, our doctors and technicians will monitor all habits closely. Blood glucose checks will be done periodically or as needed to monitor your pet's levels throughout the stay. Additional fees apply for diabetic patients.
YESNO
YESNOIF NEEDED
YESNO
YESNO
All boarders must be current on all required vaccinations and free of external parasites (ex. ticks, fleas, etc.). Village Veterinary Clinic will provide medical treatment (including vaccinations and/parasite treatment) deemed necessary for my pet while in their care. I understand there will be additional charges for treatments or any special requests needed beyond routine boarding (including any required prescription diets).
Treat as neededCall prior to treating
I have read the boarding requirements and understand the hospital's policies and acknowledge that Village Veterinary Clinic does not have overnight staff or a fire suppression system.
Signature of Owner or Agent:*

Clear
Date*

MonthDayYear
Date
Item brought from home:*
VVC is not responsible for lost items
Should be Empty: