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Pet Lodge (847) 885-2122

(847) 885-3344

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Home » Forms » Medical & Boarding History Form

Medical & Boarding History Form

Please fill out the form below to help us better care for your pet while they board with us. Remember to ask about our add-on services such as grooming upon departure, daily playtime and frozen Kong treats.

"*" indicates required fields

Client Information

First Name*

Last Name*

Phone*

Alternate Number*

This number will be used to contact you if your pet gets sick while you’re away.

Pet Information

Pet's Name*

Pet's Estimated Age or Date of Birth*

Gender*

Male

Neutered Male

Female

Spayed Female

Breed*

Color/Description*

Preferred Animal Hospital*

Animal Hospital Phone Number*

Preferred Veterinarian*

Is it OK if we take pictures/videos of your pet to use on social media and/or other Golf Rose Animal Services marketing materials?*

Yes

Please initial*

You may leave any food/treats or toys with your pet. Please initial below to acknowledge that you understand that any items you leave with your pet may become lost or damaged.*

Pet's Medical History

If your pet gets sick while you are away, we will contact you immediately. Please answer the questions below as accurately as possible so we can best care for your pet.

Does your pet have a history of any of the following illnesses or conditions?

Allergies*

Yes

Ear Infection*

Yes

Any Other Infections*

Yes

Any Injuries*

Yes

List Injuries*

Diarrhea*

Yes

Sensitive Stomach*

Yes

Arthritis*

Yes

Epilepsy/Seizures*

Yes

Heart Problems*

Yes

Respiratory Problems*

Yes

Eye Problems*

Yes

Has your pet ever ingested any household items?*

Yes

Parasites/Heartworm*

Yes

Joint Problems*

Yes

Cancer*

Yes

Thyroid*

Yes

Does your pet climb or jump fences?*

Yes

Has your pet had a heartworm test within the last year?*

Yes

If you answered yes to any of the above, please explain below including approximately when it happened.

Please list any medications, supplements or vitamins your pet is taking.*

NOTE: All medications must be brought in their original containers. We will not accept them in plastic bags or “day of the week” containers. This is to ensure the safety of your pet.

Diet

We feed Hills Sensitive Stomach (Chicken & Barley) dog food and Iams cat food. You may bring your pet’s own food/treats, and we will feed your pets according to your guidelines.

Please list your pet's food type, quantity and frequency of feeding.*

I understand that if Golf Rose runs out of my pet’s food, my pet will be fed the food listed above. Please initial.*

Vaccination Requirements

I agree that all the above information is correct. I understand that proof of current vaccinations must be provided prior to boarding. Since it is necessary for my pet to be current on all vaccinations listed below, I consent to the administration of any vaccines which are due or cannot be verified.

Required Vaccines:

Dogs:

Rabies

Distemper

Bordetella

H3N2 (K9 Influenza)

Leptospirosis (Lepto)

Cats:

Rabies

Distemper

Vaccination Records Information*

My pet is a Golf Rose Patient, and Golf Rose should have their records.

I emailed vaccination records to [email protected].

Medical Emergency Protocol

We are proud to provide the best care to your pet while he/she is staying with us. Golf Rose Pet Lodge and Golf Rose Animal Hospital comprise Golf Rose Animal Services. Pet Lodge employees are on site from 6:30 a.m. – 6:30 p.m. every day of the week. In the event that your pet needs immediate care, we have the ability to bring your pet to Golf Rose Animal Hospital.

In the event that your pet needs medical care during its stay, sign here to authorize Golf Rose permission to request medical records/boarding certificate from your veterinarian as needed:*

Emergency Care Authorization

In the event that emergency care is needed, Golf Rose medical staff needs your consent to treat your pet. Please fill in the fields below.

I, as listed above on this form, authorize the Golf Rose Animal Hospital medical staff to
treat my pet in the event of a medical emergency during boarding. If treatment is to
exceed amount written in field below, my verbal consent will be required. I understand
that any medical treatments performed will be in addition to any medical
boarding/hospitalization fees. If there is an emergency, and I cannot be contacted, I
authorize the following people to make medical/financial decisions in my stead.

Please read thoroughly and initial/sign where necessary. These instructions will be followed in the event of an emergency while your pet is boarding with us.*

CPR – denotes that you wish to have resuscitation efforts performed on your pet.

DNR – denotes that you do NOT wish any resuscitation efforts performed on your pet

Emergency CPR or DNR Initials*

If treatment is to exceed the amount below, verbal consent is required.*

Name of Authorized Person*

Phone*

Name of Authorized Person

Phone

Owner Signature*

By signing below, I certify that I am the owner or guardian of the pet/pets described
above, and that I have read all of the statements and agree to the terms and conditions
contained herein.

Owner Signature*

Owner Printed Name*

Phone

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