Drop off Date

Date*

I will pick up on:

Date*

I can be reached at:*

If I cannot be reached, call:*

Email address, in case we cannot reach you by phone:

(Optional)

DIABETIC PETS: (Additional Fees Apply) All diabetic pets will have a blood glucose test done upon check-in and check-out.

Type of Insulin*

When was the insulin last given?*

Number of units (per dose)*

Location of injection site*

Time(s) of day*

Time pet last ate*

Number of feedings per day*

How much per feeding*

Medications To Give: (Additional Fees Apply)

Medication & Next Due Doses:

Please specify

Medical, physical, or behavioral problems we should be aware of:

Items Left

MEDICAL EMERGENCY AUTHORIZATION:

I am the owner/authorized agent of the animal described below and authorize Old Dominion Animal Health Center (ODAH Center) to provide services as necessary to preserve the pet’s life and well-being, and I absolve and release ODAH Center from any loss, expense, or liability arising from the performance of these services. In the event of a medical emergency, outside of regular hours, ODAH Center may transport the pet to a 24-hour emergency clinic, and I authorize ODAH Center staff members to grant permission for diagnostics and treatment at that facility until I am able to be contacted. All fees incurred at that 24-hour emergency clinic and/or ODAH Center, as well as all liabilities or losses are the sole responsibility of the owner or agent. I understand that the center is closed and not medically staffed outside of regular business hours.

(This form is required for each visit for a hospital stay. Please complete the Advance Medical Authorization form)

Pet’s Name*

Email*

Date*

Signature*

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Name

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Diabetic Boarding Form