Jennifer Halberg, D.V.M. Peter M. Hey, D.V.M. Maria T. Hey, D.V.M. Anne M. Faseler, D.V.M. Jana Grant, D.V.M.
BOARDING ADMISSION FORM
Owner name: ______Pet name: ______
Admission Date: ______Breed: ______
Anticipated Release Date: ______AM/PM Sex: M or F Color: ______
EMERGENCY PHONE #: ______Age: ______
Current on Vaccinations: (circle one) Yes or No If no, I give Deerfield Animal Hospital permission to administer the vaccinations required for boarding at this facility.
Medications to be given:
Drug #1: ______Drug #2: ______
Dosage: ______SID BID TID QID Dosage: ______SID BID TID QID
If SID, AM or PM If SID, AM or PM
Drug #3: ______Drug #4: ______
Dosage: ______SID BID TID QID Dosage: ______SID BID TID QID
If SID, AM or PM If SID, AM or PM
Diet: (check one) _____Food provided by DAH (Purina EN dry)
_____Owner provided special diet: ______
Feeding schedule: (circle) SID or BID or Free Feed Amount/feeding: ______cups
Treats schedule: (circle) SID or BID Amount: ______treats
Belongings: (circle) N/A Leash Collar Carrier Blanket Toy Food Treats
Other: ______
Treatment or services needed before discharge: (check all that apply)
_____Exam – check: ______
____Bath ____Dip ____Nail Trim ____Annual Examination/Vaccinations
____Surgery: ______Other: ______
I am the owner of the above named animal or am responsible for it and have the authority to execute this consent. I realize the hospital admission policy requires that all pets must be free from external parasites (fleas/ticks) and that if any are found, they may be treated at my expense.
Should my pet require emergency medical treatment during the boarding period, I authorize the DAH staff doctors to perform such treatment, as they deem necessary in the best interest of my pet. I further agree to be financially responsible for such treatment.
I agree to indemnify and hold Deerfield Animal Hospital and its doctors and employees harmless from and against any and all liability arising out of the performance of any of the procedures referred to above.
Owner signature: ______Date: ______
14855 Blanco Rd. Ste. 104 ● San Antonio, Texas 78216 ● (210) 492-5575