Superior Animal Hospital & Boarding Suites - Boarding Medical Directive Form

Boarding Medical Directive Form
Owner Information

In the event of illness or injury during your pet's stay, a medical directive will allow us to act in the best interest of your and your pet.
Owner Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please enter any contact numbers below*
E-mail*
example@example.com
Pet Information
Pet's Name*
Species*
Breed*
Color*
Sex*

MaleFemale
Age*
Emergency Contact
Emergency Contact Person*

First NameLast Name
Emergency Contact Phone Numbers*
Medical Directive
Medical Illness Directive

If your pet becomes ill during their stay, please choose the course of action you would like our staff to take in order to aid your pet. *If you do not leave a directive with us, there is no dollar limit indicated, or we are unable to contact you (or your emergency contact), Superior Animal Hospital will do everything in their power to help your pet.
Non-Life Threatening Issues*

I give Superior Animal Hospital & Boarding Suites staff permission to treat non-life threatening illnesses (diarrhea, ear infections, urinary infections, etc) as the veterinarian on staff recommends for the overall well-being of my pet.I prefer to be notified if my pet has a minor illness.I do not authorize any treat without my consent.
Non-Life Threatening Cost Authorization: I authorize*

Services up to $200Services up to $500Other
Life-Threatening Issues
Rarely, life-threatening situations requiring immediate surgery or treatment may arise while your pet is boarding. In these instances, a decision must be made quickly. Costs for these emergencies can be $2000-$4000. If we are unable to reach you or your emergency contact and immediate decision must be made regarding your pet's care, please check one of the following:*

I authorize emergency treatment at SAH or Blue Pearl Emergency Service regardless of costI DO NOT authorize emergency treatment. If my pet is determined to be suffering and in medical crisis by Superior Animal Hospital or affiliated emergency vet services veterinarians, I authorize humane euthanasia.
Disclosure Signature
I certify that I have read and fully understand this form and the procedures that will take place in the event I or my emergency contact cannot be reached. I hereby release Superior Animal Hospital and Boarding Suites and all staff from any and all claims arising out of medical treatment needed for my pet. I agree to pay all medical costs accrued due to illness or injury of my pet while boarding. This medical directive will be signed at check-in and is valid for one year. Any changes are the responsibility of the client and should be presented to the SAH staff at check-in.*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Boarding Medical Directive Form

Owner Information

Pet Information

Emergency Contact

Medical Directive

Life-Threatening Issues

Disclosure Signature