UVH Unleashed Check in Form for Boarding

1
Have you called to schedule your pet's Medical Medical Supervised Stay?* This field is required.No reservation? That's okay. Go ahead and fill out the form. **Please note** filling out this form does not indicate confirmation. One of our UVHvets team members will contact you with any questions and to give you confirmation of your reservation. Thank you and we look forward to caring for your pet.
YESNO
2
Pet's Name* This field is required.
3
Owner Information* This field is required.
First Name
Last Name
###-###-#### Phone Number to reach you while you are gone
Email
Please Select
Please Select
Call phone
Text phone
Email
Will not be available via phone or email, contact emergency contact
Preferred method to contact while you are gone?
4
Emergency Contact* This field is required.
First Name
Last Name
###-###-#### Emergency Contact Phone Number
Please Select
Please Select
Yes
No
Is this person authorized to make medical decisions on your behalf in the event we are not able to reach you?
5
Name of person to pick-up if NOT you.Payment is required at time of pick up, make sure this person is aware we will check them out or you can prepay for your pet's visit. (Identification may be required)
First and Last Name
###-###-#### Phone Number
6
What date and time do you expect to check in your pet.* This field is required.Since your pet will be assigned a Doctor we ask for pets to be checked in my 5:00 pm weekdays, and by 11:00 am on Saturday. *We do not have check in/out on Sundays without permission/scheduled ahead of time.*
Date
Month
Day
Year
9
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
00
30
Minutes
AM
AM
PM
7
What date and time do you expect to check out your pet.* This field is required.Please note that check-out must be before noon to avoid an additional day fee. OUR HOURS Monday - Friday open from 7 am - 8 pm; Saturday from 7 am - 12:00 pm; we can arrange a Sunday check outs on occasion.
Date
Month
Day
Year
9
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
00
30
Minutes
AM
AM
PM
8
If it becomes necessary during your pet's visit, do you want us to administer CPR?* This field is required.
YES - CPR - Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compression, positive pressure respiration, emergency drugs or other heroic interventions, I authorize that the doctors at this hospital provide such medical care and accept responsibility of related charges.
NO - DNR - In the event that my pet's heart and or breathing should stop requiring cardiopulmonary resuscitation (CPR), I decline any and all emergency intervention. Do Not Resuscitate (DNR).
9
Has your pet had any concerns during their Medical Supervised Stay in the past?* This field is required.
YESNO
10
Please explain those concerns.How can we make this visit a good experience.
11
Food - Will you bring food or treats for your pet?* This field is required.Overnight guests will be fed dry Royal Canin Gastrointestinal nutrition. If you are bringing your pets food, please provide the food and instructions.
YESNO
12
What is the brand of food, how much to feed, and how often to feed. AND/OR What type of treats, how many and when to give.Please leave details - we want to know what to do! If your pet has food allergies please list that in CAPS.
13
What flea/tick preventions is your pet currently taking?* This field is required.So that we can make sure our records are correct.
Bravecto - Oral
Bravecto - Topical
Trifexis
Nexguard
Revolution
Advantage Multi
Simpirica
Credelio
Other
None
14
Medications - Is your pet on any medications or supplements??* This field is required.
YESNO
15
Medication Instructions:You must provide the medication in ORIGINAL container with prescription label that matches your instructions. UVHvets will not accept medications in daily pill boxes or ziploc bags. You must provide instructions if your pet takes medications in a certain way (pill pocket, peanut butter, warm chicken, etc) and provide those items. List names of meds, how much to be given, and how often and when (AM, Mid day, or PM) Example - (A) Thyrotab 1mg - 1 tab, twice a day (B) Apoquel 5.4mg - 1/2 tab once a day every morning.
16
When did your pet last take their medications?
Today - morning
Today - noon
Today - evening
Yesterday - morning
Yesterday - noon
Yesterday - evening
> 36 hours
17
Refills??Do you need any medications or preventions or food refilled while your pet is here? We will have them ready for you at check out.
Huge
Large
Normal
Small
Ok
Ok
18
When it comes to eating and drinking...* This field is required.
Please Select
Please Select
Yes
No
Is your pet eating and drinking well?
Please Select
Please Select
This morning
This evening
Yesterday evening
Yesterday morning
More than 24 hours ago
When was your pets last "normal" meal
19
Special Care Instructions Such as leash walks only, carry up stairs, feed separate from house mate, chews blankets, any verbal commands we should know, etc.
20
Belongings - are you bringing personal items from home?We provide clean fleece blankets as often as they need changing, minimum daily. Please note there is limited space for bedding and belongings from home. Please list, describe, and label all items that will be coming with your pet. Ex. green fuzzy blanket, round bed, tan carrier, black 4' leash, or orange collar.
21
Anything you want to report to a UVH Vet??What can we examine while your pet is with us? ***If your pet will have a procedure while boarding, you MUST fill our anesthesia consent form separately - found on our client tools page on our website.***
22
UVHonthego - Do you need your dog picked up or dropped off?If you mark yes, we will be in touch.
YESNO
23
E-Signature* This field is required.
Clear
Should be Empty: