Boarding Admission Form

Boarding Admission

So that our staff may prepare for your pet's arrival, this form must be completed and submitted at least 30 minutes before your pet's scheduled admission time. Please call us from the parking lot when you arrive.
Pet's name*
Your Full Name*

First NameLast Name
Cell phone number where we can reach in case of emergency*
Format: (000) 000-0000.
Pet's Arrival Date*

MonthDayYear
Date
Pet's Discharge Date (no Sundays or holidays)*

MonthDayYear
Date
Requested Discharge Time

Monday - Friday 8:30 - 11:00AMMonday - Friday 2:30 - 4:00PMScheduled Nurse Discharge ($15 additional charge)
EMERGENCY CONTACT - if we cannot reach you in case of emergency, please indicate someone whom you've designated to make medical decisions for your pet in your behalf.*

First NameLast Name
Emergency Directive:*

Yes to CPR with a Financial Limitation of $375-525 (CPR, Emergency drugs, and Medical team care)Yes to CPR with a Financial Limitation of $575-755 (CPR, Emergency drugs, Intubation & oxygen support, IV catheter, and Medical team care)No, Do Not Resuscitate (DNR)
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
DIET: All boarding guests are offered "house" Science Diet maintenance diets, unless you indicate otherwise.*

I do not have a preference, please feed the "house" maintenance diet.I have brought my pet's food - please feed the diet I have provided.Please provide the prescription diet, indicated below, for my pet while boarding. I understand charges for the diet will be added to my invoice.
Does your pet have allergies to any foods?*

NoYes, describe below
My pet is allergic to the following food:

Please indicate the type & amount of food your pet needs at each meal (use 0 for none).*

Rows	Wet Food Amount	Dry Food Amount
AM Meal
Midday Meal??
PM Meal

Does your pet need any medication or prescription diet refills while boarding?*

YesNo
Refills requested:
FLEAS: We are dedicated to a Flea Free Environment for all our patients. All boarding pets must be current on flea prevention. Pets are checked for fleas upon admission and discharge. If fleas are found on your pet, we will administer a dose of flea treatment at an additional cost.
I have treated my pet with a flea preventive in the past 30 days.*

No, please administer a dose and add it to my invoice.Yes, I have treated my pet with a flea preventive within the past 30 days (please list brand and date administered below)
Flea preventive brand & most recent date administered

MEDICATIONS YOUR PET NEEDS WHILE BOARDING? All medications must be accurately labeled for the pet named above by a veterinarian and in their original container, including medication name, strength, quantity, and current dose. Inappropriately labeled medications will not be accepted. Additional charges apply for the adminstration and supervision of medications while boarding.

Rows	Medication Name	Dose	Dosing Frequency (how often?)	Last Dose Given When?	Next Dose Due When?
Med 1
Med 2
Med 3
Med 4
Med 5

ADDITIONAL SERVICES REQUESTED:

Brushing & combing, 10 minutes ($25)Sani Hygiene Clip ($19)Nail trim ($28.5-32)Microchip & lifetime registration ($70.69)Anal gland expressed ($44)
MEDICAL SERVICES REQUESTED:

Adult/Senior wellness exam (+/- vaccines due)Wellness laboratory screeningFecal parasite screenMinor medical concern (describe below)Dental exam & cleaning with Anesthesia**Other (describe below)
PERSONAL BELONGINGS: Please list and describe any personal belongings you will bring with your pet (collar, carrier, leash, bedding, toys, food, etc. (list medications above)
ADDITIONAL NOTES:
I understand Atlantic Veterinary Hospital's payment policy and agree to remit full payment when my pet is discharged. I have informed the staff of Atlantic Veterinary Hospital of any concerns I have in regard to my pet's health and wellbeing.
Date

MonthDayYear
Date
Signature*
AVH Staff Use Only

Admitting staff 1st review __________________Nurse 2nd review & whiteboard _________________Scan & attach, fileDischarge nurse review & RTG _____________
Should be Empty: