Boarding or Hospitalization (Small Animal) Consent Form - Rogue Equine & Companion Animal Clinic

Owner or Person Responsible First and Last Name*

First Last

Emergency Phone Number*

Please provide a number we can reach you at in the event of an emergency.

Animal's Name*

Age*

Sex*

Male
Male Neutered
Female
Female Spayed

Approximate Weight*

Known medical issue(s)?*

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 unusual, dangerous or peculiar 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
None

Please select all that apply.

Preferred food, if not NPO while boarding.*

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.

Date of Last Vaccination for Canine Bordetella (If Applicable)

Date of Last Vaccination for Canine Influenza (If Applicable)

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*

Signature*

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Phone

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