Thank you for taking advantage of our Pet Valet Service! We are here to help make your life easier! Please be aware that there is a $15.00 Kennel fee to cover staff costs for housing, watering, cleaning and exercising your pet during the day. If this is not OK, please schedule a regular Out-Patient visit. We will contact you after caring for your pet with our report or to schedule a pick up time!

Date of visit

Owner's full name *

First

Last

Pet's name *

Species *

Dog
Cat
Ferret
Other

Does your Pet Have Health Inusurace? *

Yes
No
I'd like some information about Health Insurance

What Company? *

Purpose of Visit *

Give us the details!

Please prevent your pet from urinating for 3 hours prior to your visit, if possible. (Close doggy doors and restrict access to litter boxes)

For anesthetic cases*

I authorize the use of appropriate anesthetics and other medications. I understand that during this procedure(s), unforeseen conditions may be revealed that necessitate an extension of the same or different procedure(s) than set forth above. I also understand that, despite pre-surgical exams and diagnostics, unforseen conditions may exist that may cause unexpected anesthetic complications. I authorize the Doctors and Staff to do everything within their power to prevent anesthetic complications.

For anesthetic cases* *

Yes
N/A

Please check all that apply

Resuscitative directive

In the unlikely event of Cardiac Arrest, I authorize the following:

Resuscitative directive *

CPR (If I am not reachable within 15 minutes, I understand that CPR efforts will be discontinued if spontaneous breathing has not been recovered. I agree to pay all costs incurred in resuscitation.
Do Not Resuscitate and please assist humane euthanasia.

Please check all that apply

Other services

I would also like the following procedures performed

Other services *

Toenail Trim ($15.50)
Anal Sac Expression ($28.50)
Microchip/ Registration ($63.25)
Bath (40# and under: $25.00, Over 40.1# and up: $35.00))
Brush out ($5.00 to $25.00)

Please check all that apply

MEDICAL HISTORY

Please fill in the health questions below so we can be sure to cover everything while your pet is here. This also helps us keep your pet's record up to date between visits!

Lifestyle *

Please check all that apply

Where does your pet Travel?

Diet/ Nutrition *

Please check all that apply

What Brand?

Describe your pet's Home Made Diet

Which Treats or Human Food Snack?

How is your Pet's Appetite/ Drinking? *

Normal
Abnormal

Please Explain

How are your Pet's Eliminations (Urine and Stool)? *

Normal
Abnormal

Please Explain

Has Your Pet Shown Any of the Following Signs? *

Explain any of your Checks Above

Please list an Medications, Supplements your pet is Currently Taking*

Remember Heartworm Preventives, Flea/Tick Protection, Vitamins and Natural supplements

Please list an Medications, Supplements your pet is Currently Taking *

Contact information

Preferred Method of Communication Today*

It is CRITICAL that we have contact information so that you can be reached while your pet is here.

Contact information

Phone call
Text
Email

Phone

Alternate Phone

Text Number

Email *

Consent

By Typing my Name Below I allow the procedures that I have requested above to performed on my pet in my absence. I understand that I will be charged a $15.00 Kennel fee if my pet is left at the clinic after my arranged pick up time.*

I understand that there is no one on the premises after hours should my pet need in-patient treatment. *

Consent (copy) *

First

Last

Date Signed

Drop Off/Hospitalization Consent

For anesthetic cases*

Resuscitative directive

Other services

MEDICAL HISTORY

Please list an Medications, Supplements your pet is Currently Taking*

Contact information

Preferred Method of Communication Today*

Consent

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