Boarding or Hospitalization Consent Form

Prior to acceptance for boarding or hospitalization, answers to the following questions are important to ensure the safety of your animal and appropriate services are rendered.

Owners First and Last Names*
First Last
Animal's Name*
Age*
Sex*
- Male
- Male Neutered
- Female
- Female Spayed
Approximate Weight*
Horses - Short term boarding for a procedure or "other".
- Outside Paddock 24 hrs
- Inside Stall 24 hrs
- Stall at night, Paddock during day
This option is for horses only.
Known medical issue(s)?*
- NO
- YES
- UNKNOWN
- NOT APPLICABLE
Please note any known medical issues your animal may have in addition to the reason your animal is staying with us.
Any history of allergies to medication or issues with sedative or anesthetics?*
- NO
- YES
- UNKNOWN
Though your animal may not be staying for a medical or surgical procedure, it is still important for us to know if there are any known medication issues or allergies.
Any history of odd or dangerous behaviors we should know?*
- NO
- YES
- UNKNOWN
Please disclose any behaviors we should know about, those that are particularly dangerous to themselves or humans. This important for the safety of your animal.
Is your animal currently on any medication?*
- NO
- YES, LISTED BELOW
If your animal is on medication, and should remain so while with us, please list ALL types and when last given.
Is your animal insured?*
- Major Medical
- Mortality
- Loss of Use
- None
Please select all that apply.
Elective procedures or other testing*
- General Examination
- General Chemistry and Cell Blood Count
- Parasite Testing
- Microchip Placement
- Vaccination
- Other
- None
These items are in-addition to the reason for which your animal is staying with us. You will have a form to complete if your animal is staying with us for a specific purpose. The items listed below are additional and elective.
Preferred Food Type*
Please list here your preferred food choices. We will do the best too accommodate. If we cannot do so, we will notify you as soon as possible. Please send along special feed that may not be readily available to us.
Comments or special requests?
Please note here if you have any comments or special requests.
ACCURACY, AGREEMENT AND CONSENT*
I AGREE AND CONSENT
Information provided is accurate to the best of my knowledge and I understand there are additional charges for services selected above.
AGREE AND CONSENT TO INITIAL EXAM*
I AGREE AND PROVIDE CONSENT
Upon entry for boarding or hospitalization, you agree to an initial exam performed by a staff veterinarian or technician. Any abnormalities or concerns will be reported to you as soon as reasonably possible. Naturally, this exam will take place anyway in the case of hospitalization for a medical condition or surgery. Regardless, and exam will take place even for a boarding situation, and for which there may be a fee applied in addition to boarding. By checking this box, you agree to the exam and the fee.
Hospital staffing, care and liability*
I AGREE AND CONSENT
Rogue Equine Hospital and Rogue Animal Clinic (or any DBA) is not always staffed 24 hours, 7 days per week. When animals are boarded or hospitalized, video monitoring and frequent inspections are made to ensure your animal's safety and care. Being animals, things do happen from time to time and are out of anyones control. We take every precaution to ensure the health and safety of your animal for which you have entrusted us. We will notify you immediately upon identification of a problem. We require your consent to take emergency action to prevent further injury or damage, to protect life and limbs and until such time we can communicate the situation and make further decisions with you and as directed by you. We will not perform elective procedures unless explicitly acknowledged by and approved by you.
In addition, we need your explicit release of liability directed to all veterinarians, employees (including their dependents and heirs) of Rogue Equine Hospital and Rogue Animal Clinic (and all DBA's). By selecting this checkbox, you are agreeing to the above, consenting and releasing of liability as noted above.
Date of agreement and consent*
Date Format: MM slash DD slash YYYY
Signature*
Sign with finger if mobile phone or tablet, drag mouse if PC or Mac.
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.