Boarding Assessment Form

PET OWNER INFORMATION

Name*

First Last

Date of Birth*

Spouse/Secondary Owner

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How were you referred?*

Who can we thank for referring you?

Primary Contact Number: Cell/Home/Work*

Alternate Phone Number: Cell/Home/Work*

Primary Email Address*

EMERGENCY CONTACT INFORMATION

Will You Be Out Of The Country?*

Yes
No

Best Way to Reach You?

Name*

First Last

Relation To You*

Phone Number*

Email Address*

REGULAR VETERINARY HOSPITAL

Veterinarian's Name

Vet Phone Number*

AUTHORIZED LIST (Pick-up & Visitors)

Name

Number*

Name

Number*

PET INFORMATION

Pet Name*

Breed*

Age*

Weight*

Sex/Gender*

Male
Female

Sprayed/Neutered*

Yes
No

PET MEDICAL HISTORY

Has the pet been diagnosed with any medical conditions such as… IF YES, PLEASE EXPLAIN

Heart condition*

Yes
No

Please explain in detail

Thyroid disease*

Yes
No

Please explain in detail

Allergies (skin, food products)*

Yes
No

Please explain in detail

Seizures (Explain frequency, severity, behaviors to look for.)*

Yes
No

Please explain in detail

Physical limitations (Arthritis, blind, deaf, missing limb)*

Yes
No

Please explain in detail

Cancer*

Yes
No

Please explain in detail

Diabetes*

Yes
No

Please explain in detail

Chronic infections (Ear, eyes, skin, etc.)*

Yes
No

Please explain in detail

Bloat*

Yes
No

Please explain in detail

Urinary tract infections or urinary/kidney stones*

Yes
No

Please explain in detail

Any recent vomiting, diarrhea, coughing, sneezing, runny eyes?*

Yes
No

Please explain in detail

Other : (Please describe)*

Yes
No

Please explain in detail

Do you use flea/tick preventative ? Last given? Product?*

Yes
No

Please explain in detail

Is your pet microchipped?*

Yes
No

Please explain in detail

PET HISTORY

Has your pet boarded before?*

Yes
No

Prior Boarding Facility

Has your pet been known to bite, nip, lunge at or attack a person or other pet?*

Yes
No

Does your pet get along well with other animals?*

Yes
No

Are there any specific behaviors or requirements we need to be aware of?*

Yes
No

Is there any place on your pet’s body that is sensitive to the touch or does not like being touched?*

Yes
No

Does your pet fear anything in particular? Fireworks, children, sirens, men, women, etc.*

Yes
No

Is your pet protective or aggressive over toys, leashes, food, etc.*

Yes
No

What brand/flavor of food is your pet currently on?

Is your pet on medications, supplements, or preventatives?*

Yes
No

IF YES, PLEASE LIST…

Do you have Pet Insurance?*

Yes
No

Name of Pet Insurance Provider

ADDITIONAL INFORMATION (OPTIONAL)

*PETS MUST BE CURRENT ON ALL VACCINES PRIOR TO BOARDING AND DOCMENTATION WILL BE REQUESTED AT OR BEFORE TIME OF CHECK-IN

*CANINES MUST BE CURRENT ON RABIES, DHP, INFLUENZA (H3N2/H3N8), AND BORDETELLA. BORDETELLA IS REQUIRED EVERY 6 MONTHS FOR BOARDING. THE CANINE INFLUENZA (H3N2/H3N8) VACCINE MUST BE GIVEN 2 WEEKS PRIOR TO YOUR PETS BOARDING STAY. IF YOUR PETS VACCINATIONS ARE NOT CURRENT, AN EXAMINATION BY ONE OF OUR VETERINARIANS IS REQUIRED EVERY 6 MONTHS, PRIOR TO VACCINATING.

*FELINES MUST BE CURRENT ON RABIES, FVRCP, AND FELV. IF YOUR PETS VACCINATIONS ARE NOT CURRENT, AN EXAMINATION BY ONE OF OUR VETERINARIANS IS REQUIRED EVERY 6 MONTHS, PRIOR TO VACCINATING.

*FOR BEST PROTECTION, VACCINATIONS SHOULD BE GIVEN AT LEAST 2 WEEKS PRIOR TO BOARDING. LIKE THE HUMAN FLU, NO VACCINE IS 100% EFFECTIVE. WHILE WE DO OUR VERY BEST TO PREVENT ALL INFECTIOUS DISEASE, YOUR PET MAY COME INTO CONTACT AND/OR BE EXPOSED TO A RESPIRATORY DISEASE.

*ALL PETS MUST BE ON A CURRENT FLEA PREVENTATIVE. IF YOUR PET HAS FLEAS OUR HOSPITAL WILL ADMINISTER A FLEA PREVENTATIVE AT AN ADDITIONAL FEE, PAYABLE AT PICK UP TIME.

*BRINGING YOUR PETS DIET IS ALWAYS RECOMMENDED TO AVOID DIETARY RELATED ISSUES, HOWEVER WE DO OFFER A DRY KIBBLE. IF YOUR PET REQUIRES THAT WE CHANGE HIS/HER DIET, THERE WILL BE AN ADDITIONAL FEE. IF YOUR PET HAS DIARRHEA WHILE BOARDING WE WILL SWITCH YOUR PETS DIET TO “HILLS I/D DIGESTIVE CARE DRY OR WET” AND ADMINISTER “FAST BALANCE GI PASTE” OR “FORTIFLORA” TO HELP SYMPTOMS OF DIARRHEA FOR AN ADDITIONAL FEE, PAYABLE AT PICK UP TIME.

*BOARDING SERVICES ARE PAID IN FULL AT TIME OF CHECK-IN.

RELEASE FORM

*

I hereby consent and authorize you to prescribe, treat, and/or operate on ________________________. You are to use all reasonable precaution against illness, injury, escape, or death of my pet. Town & Country
Veterinary Hospital & Pleasanton Pet Hotel and its staff will not be held liable for any problems that may develop while my pet is in your care. I understand that any medical problems that may develop will be treated as deemed necessary by the staff veterinarian, emergency clinician, or emergency hospital as deemed necessary. I will assume full financial responsibility for any treatment received at Town & Country Veterinary Hospital & Pleasanton Pet Hotel or the emergency hospital if the pet is transferred. Should my pet become ill for any reason following discharge, neither Pleasanton Pet Hotel, Town & Country Veterinary Hospital, or staff will be held liable. If I request treatment for such problems following discharge, I understand I will be financially responsible for any treatment I receive at Town & Country Veterinary Hospital & Pleasanton Pet Hotel, or at a hospital of my choice. If I neglect to pick up my pet within five (5) days of the discharge date and do not notify you within the same time frame, you may assume that the pet is abandoned and you are herby authorized to dispose of the pet(s) as you deem best and/or necessary.
It is understood that your doing so, does not relieve me of financial responsibility for boarding and/or hospital care.
I have read the forgoing and agree.

I consent to the above requirements

Pet photography Release Form

*

I hereby authorize Town & Country Veterinary Hospital and Pleasanton Pet Hotel, to publish photographs taken of my pet during boarding and/or any procedure, for the use in Town & Country Veterinary Hospital and Pleasanton Pet Hotel’s print, online, and video-based materials, as well as other Town & Country Veterinary Hospital and Pleasanton Pet Hotel publications. I hereby release and hold harmless Town & Country Veterinary Hospital and Pleasanton Pet Hotel from any reasonable expectations of privacy or confidentiality
associated with the images obtained during the procedures. I further acknowledge that my participation is voluntary, and I will not receive financial compensation of any type associated with the take or publication of these photographs or participation in Town & Country
Veterinary Hospital and Pleasanton Pet Hotel marketing, educational, informational materials or other publications.
I acknowledge and agree that publication of said photos confers no rights of ownership or
royalties whatsoever. I hereby release Town & Country Veterinary Hospital and Pleasanton Pet Hotel, its contractors, its employees, and any third parties involved in the creation or publication of marketing, educational, and informational materials, from liability for any claims by me or any third party in connection with my participation.

I consent to the above statement

PET OWNER INFORMATION

EMERGENCY CONTACT INFORMATION

REGULAR VETERINARY HOSPITAL

AUTHORIZED LIST (Pick-up & Visitors)

PET INFORMATION

PET MEDICAL HISTORY

Has the pet been diagnosed with any medical conditions such as… IF YES, PLEASE EXPLAIN

PET HISTORY

ADDITIONAL INFORMATION (OPTIONAL)

RELEASE FORM

Pet photography Release Form

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