Medical Boarding General Information - Four Seasons Veterinary Specialists

(Please fill out prior to boarding date)

Client Name*

First Last

Phone Number*

Email Address*

Pet Name*

Belongings

Four Seasons Veterinary Specialists provides bedding, food dishes and water dishes to all medically boarding pets. You may provide one small blanket for your pet and one to two toys to be used during play times. You may provide your pet's bed; however, we cannot guarantee that the bed will be washed during the stay. All items must be labeled otherwise they may be marked with permanent marker. Please keep in mind that if you provide bedding and it becomes soiled, we will do our best to wash it but this is not guaranteed.

Belongings*

I have not brought any belongings with my pet.
I have brought the following belongings with my pet (carrier, toys, blankets, etc.)

List belongings*

Four Seasons Veterinary Specialists is not responsible for the loss or destruction of your pet’s belongings.

Diet

Food*

Feed Four Season’s inpatient diet (a gastrointestinal diet)
Feed diet that we brought with us

Feed diet that we brought with, which is*

Feeding Directions

Frequency*

Your pet last ate*

I brought treats*

Yes
No

Please feed treats as follows

Special Instructions regarding your pet

Special Instructions

Medication and Supplement Instructions

Medication and Supplements

Medication Name and Strength	Dosage	Frequency

*Please note that ALL medication MUST be in a labeled vial. No medications in containers, pill organizers, ziplock bags or any other storage capacity will be accepted.*

Emergency Contact(s)

In the event your pet becomes ill or injured during his/her stay with us, we will make two attempts to contact you (at least 1 hour apart) in order to discuss treatment options. Please provide us with contact information for one or more persons who you authorize to make decisions regarding the care of your pet if we are unable to reach you (or if you have instructed us to not attempt to contact you).

Name (primary contact)*

Phone Number(s)*

Name (first backup contact)

Phone Number(s)

Name (second backup contact, if any)

Phone Number(s)

Considerations for an Emergency Contact

Before beginning treatment of a patient, Four Seasons prepares a financial estimate of expected costs for approval by the client. The estimate has a high-end and low-end number, based on the information available to Four Seasons at the time the estimate is prepared. Before beginning treatment, Four Seasons requires the low end of the estimate to be paid as a deposit. The deposit may be updated during a patient’s stay. Upon discharge from the hospital or end of care of a patient, full payment of all charges is due.

Please ensure that you have discussed and arranged payment requirements with your emergency contacts. Your emergency contact will be responsible for reviewing the estimate, approving it, and providing payment of the deposit before Four Seasons begins treatment of your pet. You or your emergency contact will also be responsible for providing payment of the balance of any charges due upon your pet's discharge from the hospital or the end of your pet's care.

In addition to discussing payment arrangements, we recommend that you also discuss in advance your treatment preferences with your emergency contacts. Items to discuss may include:

Your pet(s)' current health and medical history.
Your pet(s)' current medications, if any.
Whether you would want extensive measures to be performed in your pet(s)' care, and to what degree.
Whether you would want life-saving measures (e.g., CPR) to be attempted on your pet (see page 5 of this form).
Your feelings concerning euthanasia, when it may be appropriate, and body disposition after death (e.g., burial, cremation, etc.).
Any financial constraints or limitations you may have on any of the above (e.g., is there a dollar limit that you want your emergency contacts to authorize for your pet(s)' care?)

Authorization of Emergency Contacts

I have read and I understand the considerations on the previous page, and I hereby authorize, and appoint as my agent in my place and stead, the persons named above, to make any and all decisions regarding the care and treatment of my pet(s), including but not limited to, approving medical recommendations, authorizing diagnostics, procedures, hospitalization, surgery, euthanasia and/or body care. My emergency contacts shall have the full power and authority that I would have to make such decisions, including the right to incur financial charges for my pet's treatment. I agree that Four Seasons may accept the decisions and instructions of any one my emergency contacts as if I was present and making the decisions myself.

I have discussed with my emergency contacts the payment requirements as explained above, and I have arranged with my emergency contacts payment details as necessary.

I may revoke or suspend my emergency contacts' authority at any time, either permanently or temporarily. If I relay this verbally on the phone, two Four Seasons representatives confirm this change. However, until I do so, my emergency contacts shall have the full right and authority as described herein.

Date*

Client name*

Client signature*

Witness name*

Witness signature*

Consent for CPR

Please make one of the following elections for your pet while he/she is at Four Seasons.

Consent for CPR (Please select only 1 option)*

(CPR) I give permission for the staff of Four Seasons Veterinary Specialists to perform any lifesaving efforts necessary in an attempt to resuscitate my pet should he/she stop breathing or if his/her heart stops beating while in the hospital. Additional charges will apply to begin CPR ($500-800).
(DNR except when under anesthesia) I give permission for the staff of Four Seasons Veterinary Specialists to perform any lifesaving efforts necessary in an attempt to resuscitate my pet should he/she stop breathing or if his/her heart stops beating during anesthesia only.
(DNR) If my pet’s heart stops beating or he/she stops breathing while hospitalized, I DO NOT wish for any lifesaving efforts to be performed in an attempt to save his/her life.

Best Ways To Contact Me During My Pet’s Stay

Phone Number(s)*

Email*

Destination/Hotel/Resort Contact Details

Other

Patient History

Please answer the following questions about your pet’s medical history and current clinical condition.

Heartworm, flea & tick prevention*

Yes
No

Type & last given*

Seizures*

Yes
No

Please explain & frequency*

Changes to appetite*

Yes
No

Please explain*

Recent weight changes*

Yes
No

Loss or gain duration*

Signs of lameness*

Yes
No

Which limp & how long?*

Difficulty getting up or lying down*

Yes
No

Please explain*

Increase/decrease in urination*

Yes
No

Please explain*

Increase/decrease in water intake*

Yes
No

Please explain & duration*

Vomiting and/or diarrhea*

Yes
No

Duration of symptoms*

Coughing, sneezing , difficulty breathing*

Yes
No

Please explain*

Discharge from nose, eyes, etc*

Yes
No

Recent hair loss, itching and/or growths*

Yes
No

Please explain*

Additional Information

Please use this page for any additional information or emergency contacts.

Additional Information

Email

This field is for validation purposes and should be left unchanged.