Green Cove Pet Hospital - Boarding Check-in Form Old

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This form does not qualify as a reservation request. If you need to make a reservation request, please, go to Reserve Now to submit a boarding reservation.

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General Information* This field is required.

First Name

Last Name

Email

Phone

What Type of phone is this?

Pet's Name

3

Green Cove Pet Hospital's Boarding Policy* This field is required.

4

Photography/Video Release Policy* This field is required.I hereby grant to the Green Cove Pet Hospital, the irrevocable and unrestricted right to use and publish my name, my pets name, photographs, and videos of myself and/or my pet for any lawful purpose including publicity, illustration, advertising, web-site, Facebook, Twitter, Instagram, You Tube and any other manner or medium; to alter the same without restrictions; and to copyright the same. I hereby release the photographer and the Green Cove Pet Hospital from all claims and liability relating to said photographs.

I have reviewed and Accept the Green Cove Pet Hospital's Photo/Video Release Policy.

I have reviewed and Do Not accept the Green Cove Pet Hospital's Photo/Video Release Policy.

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Boarding Consent

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Please select additional boarding services* This field is required.

Bath (based on weight)

Cut Nails $18

Fecal $28.69

None

7

If my pet is found to have evidence of an ear infection during routine ear cleaning before their bath:
Do not examine my pet Please examine my pet *

Estimated additional cost for exam, ear cytology, and medications: $83.19 to $158.36 Owner Initials *

8

Does your pet take medications?* This field is required.

YESNO

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Medications * This field is required.

Medication Name

Dosage

Time Given

Last Time Given

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication Name

Dosage

Time Given

Last Time Given

Medication Name

Dosage

Time Given

Last Time Given

Medication Name

Dosage

Time Given

Last Time Given

Medication Name

Dosage

Time Given

Last Time Given

Medication Name

Dosage

Time Given

Last Time Given

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Food* This field is required.Feeding instructions

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Belongings you brought with you?* This field is required.

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When will you drop your pet off?* This field is required.

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What time would you like to your pet ready for pick-up?* This field is required.If your pet is getting a bath, pick-up must be after 2pm.

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Do you have more than one pet staying with us?* This field is required.

YESNO

15

Is your pet seeing a veterinarian during their stay?* This field is required.

YESNO

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Resuscitation Approval

I understand that during the performance of procedure(s), unforeseen conditions may arise that necessitate an extension of the above-named procedure(s), or different procedure(s) other than those set forth above, which may include resuscitation. Therefore, I consent to and authorize the performance of such procedure(s) necessary and desirable in the exercise of the veterinarian’s professional judgment.

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In the event of cardiac arrest, please select desired response:* This field is required.

I DO request resuscitation to be performed on my animal

I DO NOT request resuscitation to be performed on my animal

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Treatment Authorization

I authorized Green Cove Pet Hospital to do whatever is necessary in case of illness or in an emergency. (Owner will be contacted as soon as reasonably possible.)

I authorize treatment up to $ * in case of emergency where I cannot be reached.

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Will your pet be released to someone other than the owner at pick-up?* This field is required.

YESNO

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I authorize my pet to be released to * on Date

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I agree that the nature and purpose of the procedures, possible alternative methods of treatment, the risks involved, and possibility of complications have been explained to me to my satisfaction. I acknowledge that no guarantee or assurance has been made as to the results that may be obtained.

Initials *

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Signature of Pet Owner or Person Responsible* This field is required.

Clear

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Printed Name* This field is required.

24

Date* This field is required.

Date