Owner Name* First Last Pet's Name*DROP OFF/PICK UP INFORMATION:Drop off date Date Format: MM slash DD slash YYYY Pick up date Date Format: MM slash DD slash YYYY Pick up time : HH MM AMPM Primary Contact First Last PhoneAlternate Contact First Last PhoneIs there someone other than yourself authorized to pick up?YesNoNameIf your pet is NOT a patient at Preston Animal Hospital please list your regular veterinarian and contact numberHospital NamePhoneIn the very rare case of life-threatening illness, we will always stabilize your pet and contact you immediately.For purposes of consent for further treatment beyond stabilization (Please choose all that apply): Please call me at my primary contact number to get consent for further treatment If you are unable to reach me, I give permission for my alternate contact to give consent for further treatmentIf unable to reach either contact (Please choose ONLY one):I give my consent for the Doctor on duty to fully treat my petI do NOT give my consent for any further treatment beyond stabilization until I can be reachedFor instances of non-life threatening illness (e.g. diarrhea, ear infection), please indicate your wishes:Treat without calling contact(s)Treat and call contact(s)Call before any treatmentFLEA PREVENTION (required):Type used:Date last applied / given: Date Format: MM slash DD slash YYYY FEEDING INFORMATION:Will you bring your own food?YesNoIf yes, what brand?Amount to feed:AMLunchPMAre you bringing treats?YesNoIf yes, give number of treats AM Lunch PMCURRENT MEDICAL CONDITIONS:Does your pet have any current medical condition(s)?YesNoIf so, please list:Current medications, dosing, and frequency: ONLY BRING MEDICATION IN ORIGINAL BOTTLES OR PACKAGING1.2.3.4.5.6.Do you have any other concerns we should be aware of (e.g. anxiety, fear-based aggression, mobility/arthritis issues)?PLEASE CHOOSE ANY A LA CARTE SERVICES YOU’D LIKE YOUR PET TO HAVE:Individual Playtime 15min ($17/day)YesNo# of days:Group Daycare w/ Hotel ($14/day - dogs only)Behavior evaluation required to participate.YesNo# of days:Deluxe Bath ($22-63):Exit Bath ($22-43):Nail Trim ($18.58)(Exit Bath Doesn’t Include Nail Trim or Ear Cleaning. The prices vary based on size and length of hair coat.)Grooming (by appt. only) Is Your Dog Getting GroomedYesNoSignature*
