Boarding Check-In Form "*" indicates required fields PhoneThis field is for validation purposes and should be left unchanged.Owner's Name* First Last Pet Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Will you be bringing your pet's food or would you like us to feed them the hospital's food?* Owner's Food Hospital Food Will you be bringing treats for your pet?* Yes No If you are bringing your own food or treats, what is the brand and types of food/treats will you be bringing?*Please give instructions on how you would like us to feed your pet, and when to provide treats. Remember to include measurements, and if you want your pet fed in the morning, evening or both.*Drop-Off Date* MM slash DD slash YYYY Pick-Up Date* MM slash DD slash YYYY Is your pet on any medications?* Yes (Please give us detailed instructions below) No Please list the name of the medication, the instructions for administering the medication and when the next dose will be due. Please note if you will need any refills while your pet is here or if we should stop the medication if we run out.*Would you like any additional services while your pet is staying with us?* Vaccinations Bloodwork Nail Trim Anal Gland Expression Intestinal Parasite Screening Ear Cytology/Cleaning Other No services needed Please type another option herePlease give us a detailed explanation of what services you would like while your pet is staying with us. i.e. what vaccinations or bloodwork you need taken care of.Personal BelongingsAll items MUST be labeled with client's last name in permanent marker. We are not responsible for lost, stolen or damaged items and do not guarantee the return of any personal belongings. Please do not bring any blankets, beds, or soft toys.CarrierQtyDescriptionCollarQtyDescriptionOtherQtyDescriptionEmergency Contact* First Last Emergency Contact Phone Number*Back-up Emergency Contact* First Last Back-up Emergency Contact Phone Number*CPR/DNR - In the unexpected event of a sudden decline of your pet's health, we want to be prepared to respond in a manner that meets your wishes. CPR/Resuscitation may include establishment of an airway, IV catheterization, administration of IV fluids, medication injections, chest compressions, intracardiac medications and much more. While the outcome of CPR/Resuscitation can vary from patient to patient, each patient that is successfully resuscitated is considered to be extremely critical and unstable. Vigilant and technical expertise is required throughout this process. The care can be costly and the outcome is uncertain.* I wish for the doctors or associates of Green Meadow Veterinary Hospital to perform CPR/Resuscitation on my pet if they suffer respiratory or cardiac arrest. I understand that my pet may or may not respond to this life-saving procedure. I understand that if my pet survives because of CPR/Resuscitation, they may have permanent health issues. I DO NOT wish for the doctors or associates of Green Meadow Veterinary Hospital to perform CPR/Resuscitation on my pet. I understand that if my pet stops breathing, and/or their heart stops beating, that my pet will die. I elect to have DNR (Do Not Resuscitate) orders placed on my pet’s record for any care received from Green Meadow Veterinary Hospital. Medical Illness: In the case of major medical concerns or illness we will attempt to contact you or your emergency contact at the number listed above as soon as possible. In the event that medical care is needed for your pet, please give us guidance on how you would like us to proceed (This does not include any charges for CPR):* I authorize GMVH to perform whatever treatments are necessary and accept full financial responsibility for all charge related to the treatment of my pet. I authorize up to the dollar amount listed below in emergency medical care during my pet's stay. This amount will not include any optional treatments you have requested above.** DO NOT administer any medical treatment until authorization is given, unless denying treatment prolongs suffering to my pet and I cannot be contacted within 1 hour. I then authorize GMVH to treat my pet according to the on-duty veterinarian's recommendations up to and including euthanasia. I will accept full financial responsibility for all charges incurred.** Treatment Costs*I authorize any treatments necessary.I authorize treatment up to $1000I authorize treatment up to $750I authorize treatment up to $500I authorize treatment up to $250I do not authorize any medical treatment.**With the above authorization we will treat your pet for minor medical concerns WITHOUT contacting you. Your boarding reservation will be confirmed by one of our customer service representatives and is not considered scheduled until it is confirmed. By signing, you state that the pet boarding is up to date on all vaccinations. Signature*
