Name *

First

Last

Phone *

Boarding date (Arrival) *

Boarding date (Pick up) *

Date

Time

Medical Concerns

Is your pet experiencing diarrhea? *

Yes
No

Is your pet experiencing sneezing? *

Yes
No

SELECT I, of

Is your pet experiencing coughing? *

Yes
No

Does your pet have any health issues (i.e. diabetes, arthritis, etc.)? *

Yes
No

If yes, please list:

Does your pet have any allergies (food/drug)? *

Yes
No

Is your pet on any medications or supplements? *

Yes
No

If yes, please list: (Medication Name, Dose, Last Time Given, Comments) *

Has your dog been treated with any flea and tick preventative in the last 30 days?* *

Yes
No

*Please list name of preventative: *

Would you like your pet to have a bath before going home? ($20.36) DOGS ONLY (Please note: boarders requesting a bath must be picked up between 3:00-4:30PM) *

Yes
No

Do you need any additional service done while here? *

Yes
No

Do you need any additional service done while here? (copy) *

Yes
No

*Please list items here *

Please let us know approximately what time you are planning on picking up so that we can make sure your pet is ready to head home! (Pick up times must be between 8AM-9AM 11AM-12PM, 3:00PM-4:30PM) Select One: *

8:30AM-11AM
3:00PM-4:30PM

Did you bring your pets own food? *

Yes
No

Name of food *

Last time fed *

Amount to feed at CLVH *

Is it.. *

Dry
Canned

OWNER MUST PROVIDE VACCINATION HISTORY IF VACCINATED ELSEWHERE

THESE ANTIGENS MUST BE UP TO DATE:
CANINE: distemper, parvo, adenovirus, parainfluenza, leptospirosis, rabies, bordetella *kennel cough
FELINE: panleukopenia, rhinotracheitis, calicivirus, chlamydophila felis, rabies
(Felines with outdoor exposure) Feline leukemia, feline immunodeficiency virus – Strongly recommended, not mandatory CANINE & FELINE: fecal exams – yearly
***Please note: if your dog has received his/her rabies vaccination at another Veterinary Hospital, we need a copy of the current rabies certificate for his/her file.

Consent to treat: In case of illness, injury, or the identification of parasites (i.e. fleas, tapeworms, etc.), I, the undersigned do hereby give my consent to the doctors of Conneaut Lake Veterinary Hospital to treat, prescribe for or handle my pet(s) while they are being boarded at Conneaut Lake Veterinary Hospital. The doctors and staff are to use all reasonable precautions against illness, injury or escape of my pet(s). However, they will not be held liable or responsible in any manner whatsoever, under any circumstances, as a result of the care, treatment, or safety of my pet(s), as I thoroughly understand that I assume all risks. *

I have read and understand.

Emergency Contact Information:

An emergency contact number MUST be provided upon check-in. The emergency contact person MUST be an adult, capable of making decisions for you regarding your pet's health and able to be reached within the continental U.S. Please note that whomever you choose as your emergency contact they are authorized to make medical decisions for your pet. You will assume all financial responsibilities for approved medical services provided during your pet's stay. Should a life-threatening (critical) medical condition occur during their stay and attempts to reach your emergency contact are unsuccessful, medical decisions regarding your pet's care will be made by the doctor on duty. You will be responsible for all medical charges associated with the management of this event.

Please list emergency contact:

Name *

First

Last

Phone *

Will you be reachable while your pet is boarding? (PLEASE SELECT ONE) *

Yes, please call anytime
Sometimes, call me first but if you cannot reach me, then call my emergency contact
No, I will not be reachable. I will contact Conneaut Lake Veterinary Hospital when I can to get updates and see if you are having any problems or concerns

IF NEEDED (List Phone #) *

I HAVE READ THE FOREGOING AND AGREE: *

Clear Signature

Signature of Owner/Representative

Purpose *

Hospitalization
Boarding

Boarding Form

Boarding Form

Medical Concerns

OWNER MUST PROVIDE VACCINATION HISTORY IF VACCINATED ELSEWHERE

Emergency Contact Information:

Please list emergency contact:

Ready to Visit

Questions?

Location

Contact Information

Hours