Skip to main content
twitter
facebook
youtube
instagram
yelp
Call Us: 925-462-1666
Visit Us: 923 Main St Pleasanton, CA
Hit enter to search or ESC to close
Home
About Us
Our Team
Giving Back
Promotions
Careers
New Clients
New Client Registration Form
Services
Wellness Care
Internal Medicine
Dental Care
Pain Management
Therapeutic Laser Therapy
Radiology and Laboratory Diagnostics
Acupuncture and Integrative Medicine
Surgical Services
Behavioral Medicine/Counseling
Nutrition and Weight Management
Pharmacy
When It’s Time To Say Goodbye
Pleasanton Pet Hotel
Boarding Assessment Form
Boarding Check-In Form
Pet Health
Pet Health Library
How-To Videos
Pet Health Checker
News
Pet Food Recalls
Product Recalls
Pet Insurance
Pet App
Online Pharmacy
Pharmacy
Purina Vet Direct
Contact
Request Appointment
search
Boarding Assessment Form
Please do not fill out this form until you have called and made a reservation.
PET OWNER INFORMATION
Name
*
First
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Spouse/Secondary Owner
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
How were you referred?
*
Stroll Magazine
YELP
Website
A Friend/Family Member
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
*
Reproductive status:
*
Male
Neutered Male
Female
Spayed Female
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
If YES, please explain
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
I AGREE
*
*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.
I AGREE
*
*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.
I AGREE
*
*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.
I AGREE
*
*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.
I AGREE
*
*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.
I AGREE
*
*BOARDING SERVICES ARE PAID IN FULL AT TIME OF CHECK-IN.
I AGREE
RELEASE FORM
I hereby consent and authorize you to prescribe, treat, and/or operate on my pet. 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 of the Release Form
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.
Pet Photography Release Consent
*
I DO Consent to the above statement.
I DO NOT Consent to the above statement.
Your Name
*
First
Last
Today's Date
*
Date Format: MM slash DD slash YYYY
Δ
Home
About Us
Our Team
Giving Back
Promotions
Careers
New Clients
New Client Registration Form
Services
Wellness Care
Internal Medicine
Dental Care
Pain Management
Therapeutic Laser Therapy
Radiology and Laboratory Diagnostics
Acupuncture and Integrative Medicine
Surgical Services
Behavioral Medicine/Counseling
Nutrition and Weight Management
Pharmacy
When It’s Time To Say Goodbye
Pleasanton Pet Hotel
Boarding Assessment Form
Boarding Check-In Form
Pet Health
Pet Health Library
How-To Videos
Pet Health Checker
News
Pet Food Recalls
Product Recalls
Pet Insurance
Pet App
Online Pharmacy
Pharmacy
Purina Vet Direct
Contact
Request Appointment
twitter
facebook
youtube
instagram
yelp