Pet's Name *

Client Name *

First

Last

Phone *

Email *

Species *

Approximate Weight *

Regular Veterinarian *

Arrival and Departure

We require pets to arrive before 2pm for Medical Boarding.

Arrival Date *

Departure Date

I will pick my pet up: *

Before 2 p.m.
After 2 p.m.

Authorized Persons

We will not release the pet to anyone other than the owner without prior consent. All pets must be picked up within 5 days of the specified check-out date. All efforts will be made to contact the owner/agent. Failure to respond or pick up a pet will result in the facility protocol for abandoned animals.

Name and Number of Authorized Person

Your pet’s RABIES VACCINATION MUST BE CURRENT for medical boarding. If you pet requires a rabies vaccination, an exam will be required. Please select from the below: *

My pet is Rabies vaccinated, I will bring proof of current vaccination if I am not a regular client
I have a waiver from my pet’s veterinarian as he/she cannot be vaccinated due to medical reasons

Brief Description of your Pets Medical Condition and Needs: *

Is there anything you would like our team to check while your pet is boarding? (Exam and other fees may apply.)

Please read and check below if your pet is a diabetic boarder:

Diabetic Boarding Authorization for Treatment: I understand that diabetes is a complicated disorder requiring a delicate balancing of food intake, amount of exercise, insulin given and other factors. Because of this, a diabetic animal may require urine and/or blood testing while boarding. I authorize the staff at Pittsford Animal Hospital to perform tests if necessary for my pet's well being.

Medications

MY PET REQUIRES MEDICATION WHILE BOARDING: I UNDERSTAND I AM REQUIRED TO BRING MY PET’S MEDICATION AND TREATMENT SUPPLIES IN THE ORIGINAL PRESCRIPTION PACKAGING WITH ENOUGH FOR THEIR ENTIRE STAY. *

Medication Name: *

Time(s) Medication Given (i.e. 8am and 5pm): *

Dose/Units Given: *

Date/Time Medication will be Last Given on Arrival Date: *

Special Instructions for giving medication: *

(ie, takes with peanut butter, pill pockets, wet food)

Add another medication?

Yes
No

Medication Name: *

Time(s) Medication Given: *

Enter time(s)

Dose/Units Given: *

Date/Time Medication will be Last Given on Arrival Date: *

Special Instructions for giving medication: *

(ie, takes with peanut butter, pill pockets, wet food)

Add another medication?

Yes
No

Medication Name: *

Time(s) Medication Given: *

Enter time(s)

Dose/Units Given: *

Date/Time Medication will be Last Given on Arrival Date: *

Special Instructions for giving medication: *

(ie, takes with peanut butter, pill pockets, wet food)

Add another medication?

Yes
No

Medication Name: *

Time(s) Medication Given: *

Enter time(s)

Dose/Units Given: *

Date/Time Medication will be Last Given on Arrival Date: *

Special Instructions for giving medication: *

(ie, takes with peanut butter, pill pockets, wet food)

Add another medication?

Yes
No

Medication Name: *

Time(s) Medication Given: *

Enter time(s)

Dose/Units Given: *

Date/Time Medication will be Last Given on Arrival Date: *

Special Instructions for giving medication: *

(ie, takes with peanut butter, pill pockets, wet food)

Add another medication?

Yes
No

Medication Name: *

Time(s) Medication Given: *

Enter time(s)

Dose/Units Given: *

Date/Time Medication will be Last Given on Arrival Date: *

Special Instructions for giving medication: *

(ie, takes with peanut butter, pill pockets, wet food)

Add another medication?

Yes
No

Medication Name: *

Time(s) Medication Given: *

Enter time(s)

Dose/Units Given: *

Date/Time Medication will be Last Given on Arrival Date: *

Special Instructions for giving medication: *

(ie, takes with peanut butter, pill pockets, wet food)

Feeding

I UNDERSTAND I AM REQUIRED TO BRING MY PET’S REGULAR FOOD WITH ENOUGH FOR THEIR ENTIRE STAY. *

Appetite *

Time(s) Your Pet is Fed (i.e. 8am and 5pm): *

Amount Per Feeding *

Any Special Feeding Instructions

If my pet becomes ill and requires medical or surgical treatment, I give my permission to examine and treat as indicated below: *

I wish to be contacted before my pet receives ANY treatment or medication. I understand if I am unreachable, the veterinarian will begin treatment to ensure my pet's well being.
Please treat any uncomplicated problems (i.e. diarrhea, abrasions) at the veterinarian's discretion and contact me ONLY in the event of a serious condition or extensive treatment.

Please read and check that you agree to the following: *

Potentially more serious problems (i.e. failure to eat, persistent vomiting, difficult urination) may warrant in-depth diagnostic testing. If the situation appears serious enough, my pet will be taken to the Animal Emergency Services at 825 White Spruce Blvd Rochester for 24-hour care. I understand I will be responsible for all related charges.*

Please read and check that you agree to the following: *

I understand that Pittsford Animal Hospital requires all personal belongings to be left at home and cannot accept responsibility for belongings left with pet while boarding.*

Please read and check that you agree to the following: *

I understand that this hospital is a flea-free facility and that if there are fleas present on my pet, my pet will be treated at the veterinarian's discretion and at the owner's expense.*

Please read and check that you agree to the following: *

By signing below you are indicating that you understand that you are responsible for all charges relating to services you request and any treatments provided should your pet become ill.*

Signature *

Medical Boarding
Check-In Form

Did you call to make your pet’s reservation?

Medical Boarding Pick-up hours:

Arrival and Departure

Authorized Persons

Medications

Feeding

Ready to begin earning rewards?

Medical BoardingCheck-In Form

Did you call to make your pet’s reservation?

Medical Boarding Pick-up hours:

Arrival and Departure

Authorized Persons

Medications

Feeding

Medical Boarding
Check-In Form