Pet Name*

Owner Name(s)

First Name	Last Name

Emergency contact name:

Phone number:*

Date of admission:

Date of Discharge:

Has Frontline/ NexGard or other flea prevention been given in the last 30 days?*

Yes
No

Type:*

Date applied:*

If no flea prevention is applied you MUST chose to either have a staff member apply a dose of Frontline Plus or administer a dose of NexGard.*

Frontline Plus
NexGard

Please select your choice:

If medications are to be administered during boarding please list medications and detailed instructions below. (fees apply)*

If medications are to be administered during boarding please list medications and detailed instructions below. (fees apply)

Type of food to be fed and amount and frequency. (once daily, twice daily, etc.).

Did you bring any personal belongings with your pet (Please list and be sure everything is labeled with your name/pet's name)

Consent*

I understand that Cleary Lake Veterinary Hospital is not responsible if my belongings are lost or damaged during my pets stay.

Signature*

Would you like us to perform any diagnostics or treatments while your pet is staying with us?*

Yes
No

Does your pet have any behavioral traits we should be aware of? (Example: Dog aggressive, separation anxiety, food protective).

Select one:*

I authorize CLVH to perform a exam and prescribe any medications that my pet may need while they are here
Please call before you perform any additional procedures.

My contact number is:*

Has your pet ever been known to chew on his/her blanket? Yes / No (check one)*

Yes
No

Consent*

I understand that all reasonable precautions will be taken to assure the safety and well-being of my animal(s) while in the hospital. I hereby authorize the clinical staff of Cleary Lake Veterinary Hospital to perform whatever procedures necessary should an emergency situation arise and I am not able to be contacted.

I have read the Cleary Lake Veterinary Hospital Boarding guidelines and agree to the terms therein.

Signature*

Name*

First Last

Date*

New Client Hospitalization Form

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