Forms

Martinez Animal Hospital

Authorization for Treatment

When Owner Is Not Present

Owner:

Address:

Pet Name: Breed: Age: _

Phone Number where owner can be reached: ____________________________________________________

In Case of Emergency Contact: Emergency Number:

I am the owner of the above named pet and I give Martinez Animal Hospital authorization to treat my pet:

_______________ while I am out of town. Dates gone _______________________. Person(s) authorized to bring my pet in for treatment: ______________________________________________________________________

_____because I am unable to personally bring in my pet. Person(s) authorized to bring my pet in for treatment: _____________________________________________________________. They are authorized until ____________ or ___ until I notify MAH in writing to void this agreement.

I give Martinez Animal Hospital further authorization to:

(Please fill out explaining to what extent you will allow your pet to be treated and if you are willing to have surgery performed if deemed necessary by the veterinarian in charge):

I am willing to spend up to $ (please enter a dollar amount for which you will be responsible).

I give Martinez Animal Hospital authorization to euthanize my pet in the event of an emergency or if treatment would exceed what I have stated above, OR if the animal is suffering and it is the only humane solution to end any prolonged suffering.

Signature Date

This form will stay on permanent record or until further notified by the owner.

MARTINEZ ANIMAL HOSPITAL

5055 ALHAMBRA AVE

MARTINEZ, CA 94553

BOARDING REGISTRATION

Please review the following information and fill out the form below when dropping off your pet:

Name:

Pet’s Name:

Today’s Date: Pick Up Date:

Contact Name: Phone: __

All boarding pets are required to have had an exam in the past year and be current on the following immunizations:

Last Exam Date: _____

DOG: Rabies: DA2PP: _ Bordetella: ________

CAT: Rabies: FVRCP: __ FELV/FIV: _____

Please list below all items you have brought with you for your pet:

Feeding Instructions

Food: Wet: Dry: __

AM Feed: PM Feed: ___

Medications

Medications Provided: Directions: _

Medications Provided: Directions:

Is there any additional information that you would like to add to this form? ____________________________________

__________________________________________________________________________________________________

I UNDERSTAND IF MEDICAL TREATMENT IS DEEMED NECESSARY FOR MY PET WHILE BEING BOARDED, IT WILL BE PROVIDED. I ALSO UNDERSTAND THAT I AM RESPONSIBLE FOR THE FEES ASSOCIATED WITH THE TREATMENT WHICH ARE TO BE PAID AT THE TIME OF PICK UP.

Signed: Date:

-----------------------------------------------------------------------Staff Use Only--------------------------------------------------------------------------------------

Entry Weight: Date: Exit Weight: Date:

TIME DROPPED OFF:_______ DATE_____________________

MARTINEZ ANIMAL HOSPITAL PATIENT ADMITTING FORM

CLIENT NAME:____________________________ PET NAME:__________________

1. WHAT CONCERNS YOU ABOUT YOUR PET TODAY? (Please be specific.)

_______________________________________________________________________

2. HOW LONG HAS THIS PROBLEM BEEN GOING ON?______________________

3. IS YOUR PET: INDOOR OUTDOOR BOTH

4. ARE THERE ANY OTHER PROBLEMS? __________________________________

_______________________________________________________________________

5. ANY: VOMITTING YES___ NO___

DIARRHEA YES___ NO___

COUGHING YES___ NO___

SNEEZING YES___ NO___

IF YES, HOW LONG?

IS YOUR PET: EATING YES___ NO___ EXCESSIVE ___

DRINKING YES___ NO___ EXCESSIVE ___

URINATING NORMALLY YES___ NO___ EXCESSIVE ___

IF NO, HOW LONG?

WHAT IS YOUR PET’S CURRENT DIET?

6. IS YOUR PET CURRENTLY TAKING ANY MEDICATION? YES__ NO__

IF YES, WHAT AND DOSAGE

7. IS YOUR PET ON MONTHLY FLEA CONTROL? YES ___ NO

IF YES, WHICH ONE?

8. IS YOUR PET ON MONTHLY HEARTWORM PREVENTION? YES ___ NO

IF YES, WHICH ONE?

9. DO YOU AUTHORIZE?

BLOODWORK YES___ NO___

X-RAYS YES___ NO___

SEDATION YES___ NO___

ANESTHETIC YES___ NO__

10. DO YOU AUTHORIZE TREATMENT

AS DEEMED NECESSARY BY THE DR. YES___ NO___ (CONTACT FIRST)

11. I AUTHORIZE MARTINEZ ANIMAL HOSPITAL TO SPEND UP TO $________.

EXPENDITURES OVER THAT AMOUNT REQUIRE MY APPROVAL.

12. IN ORDER TO TREAT YOUR PET IN A TIMELY MANNER, WE NEED TO BE ABLE TO REACH YOU BY PHONE THROUGHOUT THE DAY. LEAVE A NUMBER THAT WILL BE ANSWERED AND CHECKED: (____)__________

ALTERNATE #: (____)__________

WOULD YOU LIKE TO RECEIVE TEXT MESSAGES ABOUT YOUR PET’S STAY? YES________ NO_________

IF YOU CHECKED YES, WHO IS YOUR CELL PHONE CARRIER?______________

ADDITIONAL INFORMATION OR COMMENTS:

PLEASE NOTE: IF YOUR PET IS FOUND TO HAVE FLEAS, WE WILL APPLY ADVANTAGE AT YOUR EXPENSE.

SIGNATURE DATE

Martinez Animal Hospital

Commitment to Service & Quality Care