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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?

Medical Information:

Medical Information:

Does your pet have any current medical conditions?

If yes, please list:

List any medications your pet is currently taking (Include dose and frequency given)

Additional Services:

Please choose any a la carte services you’d like your pet to have:

Playtime 15 min:

Bath (includes ear cleaning and nail trim):

Nail Trim Only:

Grooming (by appointment only - Is your pet scheduled for grooming?)

Signature:

Today's Date: