Owner's Name *

First

Last

Phone *

Email *

Pet's name *

Age

Sex

Male
Neutered male
Female
Spayed female

Species

Dog
Cat
Other

Please specify:

LIST ALL MEDICATIONS PET IS ON, HOW OFTEN, AND WHEN THE LAST DOSAGE OF EACH WAS GIVEN:

Date and kind of last flea medication:

Date and kind of last heartworm medication:

Is your pet on a special diet?

Yes
No

Please specify special diet:

How often do you feed your pet?

How much do you feed your pet?

When did your pet last eat?

NOTE: FOR THE PROTECTION OF ALL PETS IN OUR CARE, ANIMALS WILL GET A FLEA TREATMENT, IF NECESSARY, AT AN ADDITIONAL CHARGE. ALL Animals are dismissed only during office hours: Monday thru Friday from 9am to 6pm. Saturday from 9am to 1pm. We are closed on Sundays and all major Holidays.

Personal Items with Pet

Carrier/Cage *

Yes
No

Please describe:

Collar/Leash

Yes
No

Please describe:

Bedding *

Yes
No

Please describe:

Toys *

Yes
No

Please describe:

Food/Treats *

Yes
No

Please describe:

Other Items, please describe below:

INSTRUCTIONS TO VETERINARIAN: Although I have not seen a veterinarian at the time I dropped off my animal, you have my permission: *

To perform the listed procedure(s)/service(s) only and to treat an emergency should it arise.
To perform those procedures necessary to reach a diagnosis. Do not begin treatment until I am contacted.
To perform diagnostic procedures and to begin basic or emergency treatment.
To examine and test as thoroughly as possible in order to diagnose ailment; in addition you may initiate whatever treatment or surgery you deem appropriate

Release

I certify that I own the above described animal and I do hereby consent and authorize the Santa Rosa Veterinary Hospital, and its staff to hospitalize my pet, and to administer vaccinations, medications, tests, surgical procedures, anesthetics, or treatments that the Doctor deems necessary for the health, safety, or well-being of the above animal while it is under their care and supervision. I agree to pay all fees incurred in the treatment of my pet. You are to use all reasonable precautions against injury, escape, or destruction of the animal, but you will not be held liable for any problems which might arise from the care, treatment, or safe keeping of the animal as it is understood that I assume all risks. I understand that if surgery or anesthesia is to be performed, that there will inevitably be some degree of risk, and that it is not possible for you to guarantee a successful outcome of any medical problem. If animal is not picked up within fourteen (14) calendar days after the day the animal was due to be picked up, said animal will be considered abandoned. For a minimum of ten (10) days, efforts shall be made to find a new home for said animal and if home is not found, said animal shall be humanely destroyed. It is understood that you’re so doing does not relieve me from paying all costs of your service and the use of your hospital, including the cost of keeping. I understand that veterinary service during nighttime hours and weekends is provided at the discretion of the veterinarian in charge. Continuous presence of personnel may not be provided during these off hours. I have read the foregoing and agree.

Signature

Boarding and Hospitalization Authorization Form

Boarding/Hospitalization Authorization Form

Personal Items with Pet

Release

Ready for a visit?

Have a question?

Where to Find Us

Our Hours

Get in Touch