Telford Veterinary Hospital / Boarding Pre-Registration Form

ONLINE BOARDING PRE-REGISTRATION FORM
**Important Information Please Read**

This Online Pre-Registration Form is for clients who have already scheduled an appointment for in-hospital boarding of their pets. Completion of this form does not guarentee a boarding appointment, to schedule a boarding appointment for your pet please call 215-721-6989. All attempts will be made to honor requests for drop off times though hospital staff with call to confirm your official drop off time. If you are boarding multiple pets, a pre-registration for EACH pet must be completed. Thank you for taking the time to complete this form as it speeds the intake process and reduces the time necessary while dropping off your pet. If you have any questions do not hesitate to call the office.

Form - Boarding Pre-Registration

Owner's Information (required)
First Name (required)	Last Name (required)

Phone (required)
Phone Type	Phone Number (required)

E-Mail Address :

Pet Name (required)

Emergency Contact (required)
First Name (required)	Last Name (required)

Emergency Contact Primary (required)
Phone Type	Phone Number (required)

Emergency Contact Secondary
Phone Type	Phone Number

Pet's Diet While Boarding

Brand (required)

Amount (required)

Frequency (required)

Food supplied by Whom? (required)
Owner
Hospital

Pet's Medications

Medication Name

Dosing Instructions

Medication supplied by Whom?
Owner
Hospital

Medication Name

Dosing Instructions

Medication supplied by Whom?
Owner
Hospital

Any additional Medication information or notes

Pet Boarding Care Questionnaire

Does you have any concerns about your pet's health or does your pet have any medical conditions? (required)
Yes
No

If yes, what problems or concerns do you have

Does your pet have any allergies? (required)
Yes
No

What allergies if any does your pet have?

Does your pet chew or bite bedding or toys? (required)
Yes
No

What if anything does your pet like to chew?

My pet has had in the past or currently exhibits the following behavior(s): (required)
Aggression toward people
Aggression toward dogs
Aggression toward cats
Unprovoked Agression
Playful Biting
None of the Above

Will your pet have any belonging left with them while they board? (required)
Yes
No

If yes, what belongings will be left with the pet?

Do you give Consent for Life Saving Emergency Care should the need arise? (required)
Yes
No

Note on Consent for Life-Saving Emergency Care:
In the unlikely event that your pet has a life threatening event during their boarding stay which may result in respiratory or cardiac arrest, the next step in resuscitation requires extraordinary care including cardiopulmonary resuscitation (CPR), endotracheal intubation, emergency medications and critical care. Even the most successful CPR may not restore them to good mental and physical health. These services also will require considerable time and effort as well as substantial cost. Authorization for life-saving care must be given prior to admission to alleviate confusion should this extremely unlikely event occur. When authorizing care, it is important that you understand that you are acknowledging and assuming full responsibility for the costs incurred for the resuscitation regardless of their survival. Do Not Resuscitate orders will be honored at the client's request.

Additional Requested Services during Boarding

If there are any other services your wish to have performed please list here (nail trim, vaccines)

Note regarding Additional Services:
Additional services are not covered under the prevailing daily boarding rate. Services such at nail trims, vaccines, lion cuts, grooming or other add-ons will be billed at regular hospital rates and the owner will assume full financial responsibility for said services. Pricing and estimates will be provided when the pet is dropped off and all requests for additional services will be confirmed.

Requested Drop Off Date and Time

What date are you scheduled to begin boarding your pet? (required)

On the first scheduled day your pet is to board, what time would you like to drop off your pet? (required)
10:00 am
11:00 am
3:00 pm
4:00 pm
5:00 pm

Note regarding Drop off times:
Our staff will do everything possible to accomodate your request for a drop off times for your pet but please understand that these times are based on hospital schedule availability and technician scheduling. You will receive a phone call from a hospital staff member confirming your drop off time, this will be a 10 minute appointment with a technician to review your form and any questions you may have as we process and check in your pet.

Anticipated Pick Up Date and Time

What date and time do you anticipate picking up your pet? (required)

Note on Pick Up times:
Pets must be picked up during normal hospital business hours, Monday through Friday from 9:00 am to 7:00 pm and Saturdays from 9:00 am to 1:00 pm. Pets are not available for pick up on Sundays or Holidays. Please call the office if you have to change your anticipated pick up time.