Owner Name Patient Name Phone Number Species Sex Age Arrival Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021 Departure Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021 Owner Email * Emergency Contact Emergency Contact # Diet Special Diet Our Food Purina EN Dry Medication Type of Medication 1 Dosage Requires Refrigeration? Yes No Medication Type of Medication 2 Dosage Requires Refrigeration? Yes No Medication Type of Medication 3 Dosage Requires Refrigeration? Yes No Dispensing medication/supplements will incur and ADDITIONAL FEE per day. ALL NEW PATIENTS THAT ARE ON A MEDICATION THAT WE DID NOT DISPENSE WILL REQUIRE A PHYSICAL EXAM Belongings (Please note we take all reasonable care of personal items you leave with your pet; however, we cannot be held responsible for loss or damage) Vaccinations: Ingleside Animal Hospital requires all pet(s) vaccinations to be current or owner MUST provide documentation as proof thereof. If your pet is NOT current at time of admission, or we have not been given current records, a doctor will examine and administer vaccinations needed to board. (Dogs: Rabies, Distemper/Parvo, Bordatella, Cats: Rabies, Feline Distemper, Ferrets: Rabies, Distemper) Medical Illness Policy: The doctors will make every attempt to call the emergency number listed above in the event of any medical problem(s). However, if no one can be reached please indicate your wishes, should your pet require treatment to relieve immediate discomfort or to resolve and important medical condition: (Please provide your initials in the fields provided below): Initials * Perform whatever treatment(s) the doctor deems necessary. I am fully aware that I am financially for all services provided. Your Initials * Do NOT administer any medical treatment until specific authorization is given. *I understand that animal supervision is during regular business hours and at designated times during the weekends and holidays. I agree * I agree Hospital Hours: Monday-Friday: 7am-7pm Saturday-Sunday: 8am-3pm *Dogs will be treated with a flea and tick medication at the cost upon arrival, unless a flea/tick preventative has been performed in the last 30 days (must have proof of product used). If owner applied flea/tick treatment Ingleside Animal Hospital is not responsible for any fleas/ticks found on pet once picked up. *Please call for current pricing Signature * Please type your first and last name indicating acknowledgement of these terms.
