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Medical Boarding Form

Completion of this form does NOT guarantee a medical boarding reservation. Please call 847-885-3344 to confirm a boarding reservation at Golf Rose Animal Hospital.

"*" indicates required fields

Client Information

First Name*

Last Name*

Pet Information

Last Name*

Pet's Name*

Breed*

Color*

Drop-Off Date*

Pick-Up Date*

Emergency Number*

Alt. Number

Would you like your pet bathed before pick-up?*

Express Bath: $18.50 – $23.50

Full Bath: $35.00 – $50.00 (includes brush-out, nail trim, ear cleaning & scarf)

No Grooming

I understand that, depending on the condition of my pet during their stay at Golf Rose Animal Hospital (illness/injury/temperament), the requested bathing may not be performed. Please initial here.*

DIET: List the type of food, quantity & frequency of feeding.*

I understand that I must provide my pet's food when boarding. If food is not provided, my pet will be fed Hill's Sensitive Skin & Stomach, and an additional $5 per day will be charged. Please initial here.*

I authorize Golf Rose to try different, appropriate foods if my pet does not eat the diet I provided. Please initial here.*

MEDICATION: List medication your pet will need and frequency.*

I consent to Golf Rose refilling any prescription medications that may run out during my pet's stay. Please initial here.*

OTHER: List any other items brought with your pet.*

I understand that any items I leave with my pet may become lost or damaged. Please initial here.*

EMERGENCY INSTRUCTIONS: 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.

In the event of an emergency, I give consent to*

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*

OTHER SPECIAL INSTRUCTIONS*

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].

I would like to receive updates via text message.*

Yes

Owner's Signature*

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 medical staff to treat my pet in the event of a medical emergency during boarding/hospitalization. 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.

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

Name of Authorized Person*

Phone*

Name of Authorized Person

Phone

Owner Signature*

Date*

Phone

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

Medical Boarding Form

Client Information

Pet Information

Get in touch

(847) 885-3344

Business Hours

(847) 885-3344