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*

Phone Number*

ER Contact

Pet Information

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.*

Does your pet have a sensitive stomach?

Yes

Is your pet a picky eater?

Yes

Do you authorize use of an appetite stimulant if your pet does not eat for more than 1-2 days?

Yes

Does your pet have any food allergies?

Yes

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.*

Please be advised that while we make every effort to return all items to owners upon pick up, there is a chance that any items from home may become lost or damaged (i.e. leashes, bowls, bedding, toys, etc.) For this reason, we ask that you do not bring any irreplaceable items along with your pet to barding. By signing this document, you indicate your understanding that if items from home do become lost or damaged, you, the owner or authorized agent, assume responsibility for them.*

If your pet has boarded here before, please list any changes to medications, their medical condition, or their day-to-day behavior below

Non-Emergency & Emergency Authorizations: 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*

If my pet exhibits a non-emergent health concern (ear infection, GI upset, UTI, etc.) while at Golf Rose Animal Hospital, I authorize Golf Rose to prescribe medications to treat and/or perform diagnostics as deemed necessary by the vet.

Yes

Yes, but only up to $, then I need a call

In the event of cardiac arrest, I authorize resuscitation efforts for my pet, up to and including life-saving medications and CPR. I understand that additional costs will be incurred if CPR is my selection

No, my pet is DNR (do NOT resuscitate)

Yes, perform CPR on my pet

Golf Rose medical staff to treat my pet in the event of an emergency. I understand that I will be responsible for the cost of the medical care provided. Please indicate, in the box to the right, how much you authorize spending for an emergency before your verbal consent is required. We ask this because we may need to act first and call later when the patient is stable.

I authorize

I authorize $ before a call/verbal consent is required

If there is an emergency, and I cannot be contacted, please contact the person named here. They have my permission to make medical decisions on behalf of my pet, up to and including discontinuing CPR, performing diagnostics, performing humane euthanasia, etc. Emergency contact phone number

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

If yes, what phone number should we text?

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*

MM slash DD slash YYYY

For hospital use only

Intake Technician

Intake Witness

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

Medical Boarding Form

Client Information

Pet Information

For hospital use only

Get in touch

(847) 885-3344

Business Hours

(847) 885-3344