villagevethouston.com - 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:

Date

Pick up date and time:

Date

Hour MinutesAM/PM Option

Emergency Contact Name:

Emergency Phone #:

Please enter a valid phone number.Format: (000) 000-0000.

Relationship:

Insulin and Syringes brought:

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.

Would you like your pet to be bathed on the day of discharge? If yes, plan pick up after 1pm

Flea Treatment?

Does your pet suffer from noise adversities, such as thunderstorms? *If yes, for the comfort and security of your pet, we may medicate if the veterinarian feels it's necessary. *

Has your pet ever been known to chew on, eat, or ingest bedding, blankets, or towels?

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).

In the event of an illness or medical emergency, I authorize Village Veterinary Clinic to treat my pet:

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:

Date

Item brought from home:

VVC is not responsible for lost items