Canine Day Stay Consent Step 1 of 19 5% Owner's Name:(Required) First Last Emergency Phone Number(Required)Email(Required) Pet's Name:(Required) First Services and Vaccines Needed: (Check all that apply)(Required) Physical Exam (Mandatory for day care/boarding patients) Rabies Vaccine (Mandatory by law and for day care/boarding patients) Distemper DA2PPv + Lepto4 (Mandatory for day care/boarding patients) Bordetella & Parainfluenza (Kennel Cough Vaccine) (Mandatory for day care/boarding patients) Canine Influenza Vaccine (Mandatory for day care/boarding patients) Canine Lyme Vaccine My pet is up to date on vaccines My pet is currently sick, and I would like the doctor to perform an exam before we decide on vaccinations. Labwork and Diagnostics Needed: (Check all that apply)(Required) Intestinal Parasite Evaluation (A dewormer may be prescribed pending results) (Mandatory for day care/boarding patients) Canine Junior (6 years and under) Early Detection Blood work including heartworm test Canine Senior (7 years and older) Early Detection Blood work including heartworm test & urinalysis Heartworm Test and Tick Titer (Combo Only) Other service/labwork My pet is up to date on labwork/diagnostics My pet is currently sick, and I would like the doctor to perform an exam before we decide on labwork and/or diagnostics. If above you selected "Other service/labwork" please explain below Was any medication(s) administered to your pet in preparation for today's visit?(Required)(For Example: If Benadryl was administered, please specify whether it was the adult or children’s formulation.) Yes No Name of Medication:(Required) Name of Medication Amount of medication given:(Required) Name of Medication Time medication was given: Hours : Minutes AM PM AM/PM Was a 2nd medication administered to your pet in preparation for today's visit?(For Example: If Benadryl was administered, please specify whether it was the adult or children’s formulation.) Yes No Name of 2nd Medication:(Required) Name of Medication Amount of 2nd medication given:(Required) Name of Medication Time the 2nd medication was given: Hours : Minutes AM PM AM/PM Has your pet taken any other medications in the past month?(Required)For example: Daily medication, prevention, supplements and or antibiotics. Yes No What were the names of the medications and how much was given?(Required) Add Remove Please limit the personal items you bring while your pet is staying with us to ONE special toy/item. JAH provides bedding for pets whose pet parents approve of bedding.(Required) I understand I approve for my pet to have bedding while staying at Johnston Animal Hospital and I verify my pet has not had problems in the past eating or chewing on bedding.(Required) Yes No Does your pet have one special item you are leaving with them? Yes No Please list the one special item you are leaving with your pet:(Required) Does your pet have any medications or supplements that need to be refilled?(Required) Yes No Please list the medications or supplements that need to be refilled:Indicate the amount of medication you would like dispensed (e.g., preventatives: 1 month, 6 months, or 1 year; other medications: 30 count or 90 count). Addtional Optional Services(Required) Clean Ears Express Anal Glands Pedicure – Cut Nails Pedicure – File Nails No Additional Services Rabies Vaccination Acknowledgement – In accordance with North Carolina law and for the safety of others, I acknowledge that my dog and/or cat must have a current rabies vaccination. If my pet has already been vaccinated, I agree to provide official documentation to Johnston Animal Hospital PRIOR to my pet's appointment, or authorize my previous veterinary provider to do so on my behalf. If I do not provide valid proof of current rabies vaccination before the appointment, I understand that: My pet will receive a rabies vaccine during the visit if the attending veterinarian determines it is medically safe to do so. I am responsible for any charges associated with the rabies vaccine. If the veterinarian determines it is not medically safe at that time, the rabies vaccine will be administered at a future visit when it becomes safe. I also understand that declining the rabies vaccine places me in violation of North Carolina law. In such cases, Johnston Animal Hospital reserves the right to refuse service, and my pet will not be seen.(Required) I understand and agree with the Rabies Vaccination Acknowledgement above I understand that Johnston Animal Hospital is not open 24-hours; therefore, if my animal is hospitalized or boarding overnight there will not be 24-hour supervision. If I desire 24-hour supervision of my animal, then I understand that I can request to transfer my animal to a 24-hour veterinary emergency or specialty hospital. I acknowledge that the responsibility for transporting my pet to the 24-hour emergency/specialty facility and the additional fees incurred for care at that facility would be my own.(Required) Yes, I understand I understand that my pet must be free from internal and external parasites and be up to date on all preventative vaccines. This policy protects my pet as well as other animals during their stay in the hospital. If my pet is not current on vaccinations or shows signs of any parasites, these treatments will be done at my expense.(Required) Yes, I understand I understand that if my pet has signs of fleas or ticks, the team at Johnston Animal Hospital will administer a dose of Bravecto to my pet. I understand that I will be charged an additional fee for this treatment.(Required) Yes, I understand I understand that if pet has soiled themselves, the team at Johnston Animal Hospital will give a necessary freshening bath. I understand that I will be charged an additional fee for this treatment.(Required) Yes, I understand Pre-Anesthetic Blood work(Required)Pre-anesthetic blood work is used by the doctor to evaluate organ function and metabolic function before anesthesia. Understanding blood work values helps the doctor to determine the safest anesthetic choice(s) for your pet. The cost of the blood work will be included in your pet’s Health Care Plan. Yes, I understand Life-Saving Emergency Care(Required)I understand that all procedures will be performed to the best of the abilities of the team at Johnston Animal Hospital. However, I accept that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results. Select ONE option below for your pet so we can be prepared in an event that life-saving emergency care is needed: YES, the hospital doctors and team have my permission to provide emergency treatment and I agree to pay for these services even if the cost exceeds the health care plan. NO, the hospital doctors and team do not have my permission to provide emergency treatment; therefore, I am choosing “Do Not Resuscitate” for my pet. Typed Signature(Required)I certify that I am the owner, or authorized agent for the owner. I hereby consent to and authorize the doctors and team of Johnston Animal Hospital to admit this pet and perform the procedure indicated on this form. I understand I will be given a health care plan to review at the time of my pet’s admission to Johnston Animal Hospital. I acknowledge that I am responsible for payment in full for the procedures and treatments at patient discharge. Signature
