915 Bennett Point Rd. Queenstown, MD 21658
[email protected]
410-827-4245
Canine Country Club
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Senior Pet Form
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Contact Us
Home
About
Our Team Members
Services
Boarding
Grooming
Training
Make A Reservation
Senior Pet Form
Canine Photo Art
Contact Us
Senior Pet Form
Home
Senior Pet Form
Here at Canine Country Club we do everything we can to make the boarding experience as comfortable and safe as possible for our elderly guests. Despite our best efforts, being away from home may cause existing conditions to worsen or underlying conditions to become apparent.
Date
MM slash DD slash YYYY
Pet Owner's Name
First
Last
Mobile Phone Number
Email
Senior Pet's Name
Breed
Age
Veterinary Clinic
Please check all of the below observations that apply to your pet. Please detail the checked conditions in the space below or add anything that was not listed.
Difficulty Climbing Stairs
Stiffness
Vomiting
Increased Urination
Itching
Vision Problems
Tremors/shaking
Lethargic
Increased Thirst
Limping
Skin/Coat Changing
Confusing
Bad Breath
Hearing Problems
Decreased appetite
Weight Change
Lossof Bowel/Bladder control
Lumps/Bumps
Constipation
Changes in Sleep Patterns
Bloating
Seizures
Coughing
Diarrhea
Panting
Surgery
Notes or Issues not mentioned above:
We will ALWAYS try to get in touch with you immediately in an emergency.
In the event that my pet becomes ill while myself and any emergency contacts I have listed are unreachable, I give my permission to:
Take all possible measures stabilize, regardless of cost*
Do minimal to stabilize
*Regardless of cost means that, in a life threatening emergency, all medical and life preserving options will be pursued.
In the event of death:
Hold at veterinarian until I return
Individual cremation at veterinarian (retain ashes)
Non-individual cremation at veterinarian (do not retain ashes)
Pet Owner Signature
*
First
Last
Date
MM slash DD slash YYYY