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Owner's Name (first and last):

Pet's Name:

Email Address:

Primary Contact Phone:

Alternate Contact Phone:

Breed:

Sex:

Age:

Drop Off Date:

Pick Up Date:

Approximate Pick Up Time:

Hospital Name:

Hospital Phone Number:

Treatment Consent:

Treatment Consent:

*** In the very rare case of life threatening illness, we will always stabilize your pet and contact you immediately.***

For purposes of consent for further urgent treatment beyond stabilization (please choose all that apply):

Please call me at my primary contact number to get consent for further treatment
If you are unable to reach me, I give permission for my alternate contact to give consent for further treatment

If unable to reach either contact during an emergency:

I give my consent for the doctor on duty to fully treat my pet
I do NOT give my consent for any further treatment beyond stabilization until I can be reached

Boarding Notes

Boarding can sometimes be a stressful event and cause a patient to have diarrhea, occasional vomiting, and/or not eating.

In these instances: I give Clayton Animal Hospital permission to treat my pet symptomatically. If the event becomes more serious and continues after the initial treatment has been started a doctor will call you to discuss next steps in treatment.

I give permission for treatment
I DO NOT give permission for treatment

Belongings

Belongings:

For the safety of your pet and to prevent lost items: Bedding, blankets and toys are prohibited.

Feeding Instructions:

Feeding Instructions:

Will you bring your own food?

If yes, what brand?

Feed Amount, AM

Feed Amount, Lunch

Feed Amount, PM

Are you bringing treats?

If yes, how many treats should be given in AM / PM?

Behavior:

Behavior:

How is their appetite?

Normal
Increased
Decreased

How is their thirst?

Normal
Increased
Decreased

How are their urination pattern?

Normal
Abnormal

Describe if abnormal urination (frequency, accidents?)

How is their behavior activity?

Normal
Lethargic

Any know allergies to food or medications?

If yes, please list those food and/or medication allergies.

Insulin Information:

Insulin Information:

*** PLEASE ALERT OUR TEAM AT DROP OFF WHEN THE LAST TIME YOU GAVE YOUR PET’S INSULIN. ***

What type of insulin is your pet on?

How many units does your pet receive?

What time of day does your pet receive it?

List any other medications they are currently taking (include dose and frequency given):

Notes

At times we may need to check a blood sugar level to ensure that it is safe to administer insulin. We typically do not contact owners regarding this unless we are concerned about a problem.

Rarely a diabetic episode can occur. If there is an issue, we will first stabilize your pet if they are having a more serious diabetic episode and then contact you immediately.

Signature:

Today's Date: