Medical Record Upload

Instagram

This field is for validation purposes and should be left unchanged.

Client Information

Current client?

Yes
No

How did you hear about us?

Post Card
Friend/Referral
Google
Facebook
Drive by
Other

Describe how you heard about us.

Client Name

First Last

Address

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

Primary Cell Phone

Email Address

Secondary Contact Person

Secondary Contact Person Phone

Emergency Contact

Emergency Contact Person

Emergency Contact Phone

Pet Information

Pet Name

Species

Breed

Sex

Male
Female

Spayed/Neutered

Yes
No

Coat Color

Age or Birthdate

Last Heat Cycle (if intact female)

Drop-Off and Pick-Up Information

Drop-off Day

What day will you be dropping your pet(s) off?

Pick-up Day

What day will you be picking your pet(s) up?

Drop-Off Time

Pick-Up Time

What are you bringing?

Please describe in detail everything that you are bringing with your pet, so that we ensure you get it back when you pick your pet up.

Are you bringing your own food?

Yes
No

Purina EN will be provided. If pet does not eat dry, moist Purina EN will be substituted. Additional fees will apply.

Current Diet and Amount Fed

Current Medications (Name, Frequency, mg/Dose)

Must come in ORIGINAL container (for easy identification).
*Additional fees will apply for daily administration of medications.

Health and Behavior

Changes in the last 2 weeks.

Does your pet have any concerning Health Issues?

Change in appetite, water consumption or experiencing weight loss?
Vomiting, diarrhea or change in urination?
Difficulty rising/signs of osteoarthritis?
Any coughing or sneezing?
Any changes in behavior or aggression in the last 10 days?:
No concerning health issues.

Change in appetite, water consumption or experiencing weight loss

Vomiting, diarrhea or change in urination?

Difficulty rising/signs of osteoarthritis?

Any coughing or sneezing?

Any changes in behavior or aggression in the last 10 days?

Medical History

Previous Medical Problems or Surgeries?

Yes
No

please explain

Heartworm Prevention (Product, Last Given)

Flea/Tick Prevention (Product, Last Given)

Flea/Tick Prevention Policy

All boarding pets must have current flea/tick prevention (approved products: Simparica Trio, Bravecto, Bravecto Quantum, Simparica, Nexgard, Credelio, Advantage Multi, and Revolution). If not due or do not have any of the approved products, we will apply topical Advantix (dogs) or Covetrus Para Monthly Plus (cats). Additional fees apply.

Please select one:

I will bring my own prevention
DAMC to Apply topical prevention and I acknowledge the additional fee

Product name (if bringing your own prevention)

Vaccination Status

Is your pet due for vaccines upon drop-off for boarding?

Yes
No
Unsure

If yes or unsure, please contact us immediately: (727) 738-2273

For your pet's best protection, vaccinations need to be current at least 3 weeks prior to boarding.

Does your pet have a history of Vaccine Reactions?

Yes
No

Pre-medication option (if due for vaccines)

We use an injection of diphenhydramine to reduce risk of vaccine reactions. Additional fees will apply.

Yes
No

Vaccine Information from Another Hospital

Veterinary Hospital Name

City of Hospital

Hospital Phone Number

Hospital Email (if known)

Pet Name (as registered at the hospital)

Owner Name (as registered at the hospital)

Veterinary Exam (if due)

Owner concerns/questions for exam?:

Yes
No

please explain

Emergency Medical Decisions

In the event of an emergency, please select one of the following options:

Authorize Veterinary Discretion: I authorize the veterinarian to exercise their professional judgment and proceed with appropriate treatment until I am contacted. I understand that I will be responsible for all charges incurred.
Do Not Treat Until Contacted: I instruct the veterinary hospital to do nothing until I am contacted, understanding that in some situations, this decision may impact my pet's health, up to and including death. This includes Do Not Resuscitate (DNR) orders.

Emergency number to call first

Additional Information

Is there any other information we should know about your pet while boarding with us (e.g., special needs, preferences, or concerns)?:*

Yes
No

please explain

Items to Bring

Small blankets
Pet’s treats (no rawhide or bones)
Pet’s food
Pet’s medications
Toys (non-shreddable, non-consumable)

Items NOT to Bring

Personal bowls (unless a slow feeder)
Rawhide or bone treats (including beef hide)
Hooves
Beds that cannot be easily washed

Acknowledgment

Signature (type your full name)*

I certify that the information provided is accurate to the best of my knowledge. I understand the hospital’s policies regarding vaccines, flea/tick prevention, and boarding fees, and I consent to necessary treatments as outlined in the boarding estimate.

Date

Contact Number

Medical Appt Check-In Form

Medical Appt Check-In Form

APPOINTMENT CHECK IN

Pet 1

Pet 2

Pet 3

Why Am I Here Today?