John case With

Name *

First

Last

Spouse / Co-Owner Name

First

Last

Phone *

Email *

Pet's Name *

Has Your Pet Stayed With Us Before? *

Yes
No

DROP-OFF: Date & Time *

Date

Time

PICK-UP: Date & Time *

Date

Time

The following individuals have permission to pick up, drop off, or authorize treatment for the patient: *

Anyone not on this list will not be authorized to pick up, drop off, or make any medical or financial decisions unless approved by you, the owner.

Emergency Contact

Name *

First

Last

Emergency Contact #1

Phone *

Emergency Contact #1

Add a Second Emergency Contact? *

Yes
No

Emergency Contact #2

Name *

First

Last

Emergency Contact #2

Phone *

Emergency Contact #2

Add a Third Emergency Contact? *

Yes
No

Emergency Contact #3

Name *

First

Last

Emergency Contact #3

Phone *

Emergency Contact #3

In the event my pet becomes ill while staying at Port St. John Veterinary Hospital, I authorize the attending veterinarian to administer treatment deemed therapeutically and/or diagnostically necessary. I also consent to the administration of anesthetics and any emergency surgical procedures, if required. I understand that Port St. John Veterinary Hospital will make every effort to contact me prior to treatment in the case of a medical or surgical emergency. *

YES – Please treat my pet. I understand that I will be responsible for any charges accrued.
NO – Do not treat my pet without my permission (besides life saving measures).

Is your pet on any medications? *

Yes
No

Please list name of medication, administration route, frequency of medication. *

Has your pet been fed and medicated (if applicable) today? *

Yes
No

Did you bring your own food? *

Yes
No, please feed kennel food.

Feeding Instructions *

How much? How often?

Do you have any special instructions, are there any medical problems and/or behavior problems (food aggression, dog aggression, etc.) relating to your pet? *

Please list any additional phone numbers or email addresses that we would be able to reach you in the case of an emergency.

Owner's Signature *

Clear Signature

Today's Date *

Boarding Form

Boarding Form

Emergency Contact

Emergency Contact #2

Emergency Contact #3

Ready for a Visit?

Contact Us

Location

Hours

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