Boarding Drop-Off PATIENT BOARDING DROP-OFF INFORMATIONCLIENT*PATIENT:Name*HISTORYAre there any known problems that require us to address them while your pet is staying with us?* Yes No if Yes, please describe* I authorize an examination by a doctor if there is a known problem and my pet has not had an exam within the last year for this problem My pet has a special diet/its own food *FoodFeeding instructions Is your pet eating normally?* Yes No If NO, DESCRIBE*Is your pet Drinking Normally* Drinking normally Drinking less than normal Drinking excessive quantities Is your pet vomiting?* Yes No if Yes, please describe*Does your pet have diarrhea?* Yes No if Yes, please describe* I authorize the staff at Mid-Valley Veterinary Hospital to change my pet's diet should it start vomiting, have diarrhea or refuse to eat during its stay. Is your pet currently on any medications?* Yes No If YES*MEDICATIONLast given Some animals exhibit anxiety while staying away from home. If they exhibit extreme anxiety to the point of not eating or destructive behavior, do we have permission to sedate?* Yes No I understand that I will be charged a higher boarding rate if medications or a special diet has to be given during the stay. In the event of a life-threatening condition, we will stabilize your pet and call you as soon as possible. Please make certain you leave a phone number where you can be reached. CPR/DNRIn the event that your pet should experience cardiac or respiratory arrest while boarding, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pet's status? By consenting to this service, you are also acknowledging that certain charges will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. I agree to CPR being performed in case of arrest and agree to any financial obligations as a result of CPR being performed regardless of outcome. I elect a “Do Not Resuscitate” status in case of arrest. PHONE NUMBER(S) WHERE YOU CAN BE REACHED TODAY*If you cannot be reached at the phone number provided above, we will not proceed with the procedure or treatment. This can cause delays in pick-up times, and our ability to treat your pet. You will be still be charged for any services performed.Owner Release and ConsentMVVH Orland, Inc., doing business as Mid-Valley Veterinary Hospital, will use all reasonable precautions against injury, escape, or death of your pet. In the event complications arise and I cannot be immediately contacted at the below-listed phone number, Mid-Valley Veterinary Hospital is directed to make the decision(s) it deems best for my pet. I have read the foregoing, understand what it says, and agree Payment for services rendered is due at time of discharge. MVVH Orland, INC. d.b.a. Mid-Valley Veterinary Hospital.Signature*Date* MM slash DD slash YYYY PHONE NUMBER(S) WHERE YOU CAN BE REACHED THROUGHOUT YOUR ABSENCE*
