Name
*
First Name
Last Name
Spouse (Other) Name
First Name
Last Name
What is Spouse (Other)'s relationship to you?
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
(###)
###
####
Cell Phone
*
(###)
###
####
Work Phone
(###)
###
####
Spouse (Other) Phone
(###)
###
####
Email
*
How would you like us to contact you for appointments?
*
How would you like us to remind you when your pet is due for vaccinations/exam/tests?
*
Drivers License Number (For check writing.)
How did you hear about us? (Please list any names so we can thank them for their referral!)
*
Are you one of the following? (ID will be verified upon arrival)
*
Military
Law Enforcement
Firefighter
Paramedic
None of the above.
Pet 1: Name
*
Pet 1: Sex
*
Male
Female
Pet 1: Is your pet Neutered/Spayed?
*
Yes
No
Unsure
Pet 1: Date of Birth
*
If you do not know your pet's birthday, you can give your closest guess.
MM
DD
YYYY
Pet 1: Color
*
Pet 1: Microchip #
Pet 1: Any allergies known?
*
Yes
No
Pet 1: Please list below.
Pet 1: Any diagnosed illness or injuries?
*
Yes
No
Pet 1: Please list below.
Pet 1: Please list below.
Pet 1: Please list all the medications your pet is taking (including over the counter medications).
*
Pet 1: More information:
Please let us know if your pet has any behavior or medical problems that we need to watch for while they are visiting us.
Pet 1: My pet will have access to a raised hammock bed. If this bed is destroyed, I understand that I will be charged a damage fee of $36. Please do one of the following:
*
My dog is not destructive; leave bed.
My dog is destructive; take bed away.
I don't know if my dog is destructive; leave bed and I will pay charges.
I don't know if my dog is destructive; take bed away.
I have a cat; this does not apply.
Pet 2: Name
Pet 2: Sex
Male
Female
Pet 2: Is your pet Neutered/Spayed?
Yes
No
Unsure
Pet 2: Date of Birth
If you do not know your pet's birthday, you can give your closest guess.
MM
DD
YYYY
Pet 2: Color
Pet 2: Is your pet microchipped?
Yes
Yes, but I don't know the number.
No
No, but i'm interested in getting one.
Pet 2: Microchip #
Pet 2: Any allergies known?
Yes
No
Pet 2: Please list below
Pet 2: Any diagnosed illness or injuries?
Yes
No
Pet 2: Please list below.
Pet 2: Please list below.
Pet 2: Please list all the medications your pet is taking (including over the counter medications.)
Pet 2: More information:
Please let us know if your pet has any behavior or medical problems that we need to watch for while they are visiting us.
Pet 2: My pet will have access to a raised hammock bed. If this bed is destroyed, I understand that I will be charged a damage fee of $36. Please do one of the following:
My dog is not destructive; leave bed.
My dog is destructive; take bed away.
I don't know if my dog is destructive; leave bed and I will pay charges.
I don't know if my dog is destructive; take bed away.
I have a cat; this does not apply.
Please list where vaccines were given or your previous veterinary office and phone number if available for each pet. (If your pet or pets were listed under a different name, please let us know.)
*
Multiple Boarder Waiver: I have given permission for my pets to be housed together and/or play together while boarding at the Davis Pet Hotel & Spa. I understand that while in a new environment, my pets may become stressed and act in ways that are outside of their normal behavior. They may have gastrointestinal problems, poor appetite, and even fight with one another. I understand that if any of my pets display any of the issues listed above, that the staff of Davis Pet Hotel & Spa will separate my pets for their protection and will contact me informing me of the issue. I will not hold Davis Pet Hotel & Spa or their staff liable for my pets' injuries or illnesses that may occur as a result of my pets being housed or exercised together. I agree to pay for treatments rendered due to these illnesses or injuries. I understand that if my pets are housed separately, they will be boarding at standard rates from the incident on, and not the discounted rate when sharing a boarding space. If my pets have had a physical altercation/fight during a past boarding visit, it is Davis Pet Hotel & Spa's best recommendation that they do not board together for future stays. Despite this recommendation, if I insist on having my pets board together, I understand that I am responsible for any damages, injuries, or illnesses that may occur.
*
I understand and agree.
I do not have multiple pets boarding together.
I understand that my pet's belonging(s) will be with my pet unless deemed unsafe without supervision by the Hotel Attendants. I understand that during times of stress, my pet may destroy, lose, or soil their belongings. If the staff of Davis Pet Hotel & Spa at any time deems that my pet is not safe with their items during their stay, we will pull the items out of their suite and attempt to contact you to inform you. The staff of Davis Pet Hotel & Spa is not responsible for damages or losses to belongings.
*
By signing this once a year agreement, I understand that my pet is required to be current on vaccinations (Rabies, DA2PPV/FVRCP, Bordetella, Bivalent Flu) that are necessary for boarding and free of parasites (fleas, ticks, worms) for their protection as well as the protection of the pets in this facility. Treatment will be at my expense.
*
An intestinal parasite exam ($32) will be done on my pet should they display diarrhea issues. This is necessary to protect all boarders and patients. Treatment will be at my expense.
*
I understand that I will be checking the information I have provided at each check-in for my pet's stay and will initial the form at each visit. If there are any changes necessary, I will inform the staff member upon check-in.
*
I verify that I understand the above information, and will discuss any updates throughout the year as indicated.
*
Treatment Authorization
*
I am the owner/authorized agent for the animal named above, and I am 18 years of age or older.
I give permission for the doctors and staff of Davis Animal Hospital to examine and treat my pet as I have requested.
I understand that medical therapy of any kind involves some risk to my pet, including but not limited to adverse drug reactions, and agree to hold the hospital and its employees harmless in the absence of negligence, in connection with these procedures.
I acknowledge that no guarantee or assurance
has been made to me as to the results that may be obtained.
In the event of an emergency I understand that life saving measures will be initiated while an attempt is made to contact me. If I cannot be contacted at the listed numbers, the doctors and staff are directed to make decisions deemed best for my pet.
I understand that payment is due when services are rendered, and I agree to pay for those
services rendered.
I understand that interest will accrue on any balance outstanding over 30 days at 1.5% per month (18% annually) and a $5.00 handling fee will be assessed on each monthly statement.
I agree to pay for these and any additional cost incurred by the hospital in the collection of any outstanding debt for services rendered.
I appoint Davis Pet Hotel & Spa, a division of Davis Animal Hospital, as my attorney-in-fact, to do all that is necessary or desirable for maintaining the health of my pet listed above, specifically, to approve and authorize any and all medical treatment deemed necessary by a duly licensed veterinarian and to execute any consent, release or waiver of liability required by veterinary authorities incident to the provision of medical, surgical or other essential care to my pet by qualified veterinary medical personnel. This document is good for the year it was signed.
*
I agree.
I disagree.
I understand that if I am not able to be contacted for verbal or written approval, that treatment will not exceed the amount authorized above.
*
I understand.
I do not understand.
Based on the emergent nature of need, my pet will be treated by a veterinarian on staff at Davis Animal Hospital or transported to the Veterinary Emergency Referral Center if after veterinary office hours.
*
I understand.
I do not understand.
I am responsible for all charges incurred at Davis Animal Hospital and/or the Veterinary Emergency Referral Center.
*
I understand.
I do not understand.
In the unlikely event of a cardiac or respiratory arrest, we will do all we can to resuscitate your pet. I understand that I am responsible for any additional costs related to this event.
*
Please resuscitate my pet. I will pay any additional charges this may incur.
Do not resuscitate my pet.
Emergency Contact #1 Name
*
First Name
Last Name
Phone Number
*
(###)
###
####
Relationship to Owner
*
This contact can make medical decisions for my pet on my behalf.
*
Yes
No
Emergency Contact #2 Name
First Name
Last Name
Phone Number
(###)
###
####
Relationship to Owner
This contact can make medical decisions for my pet on my behalf.
Yes
No
Emergency Contact #3 Name
First Name
Last Name
Phone Number
(###)
###
####
Relationship to Owner
This contact can make medical decisions for my pet on my behalf.
Yes
No
