ROOSEVELT VET
ROOSEVELT MANSION
URGENT CARE
845.279.6578 |
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MEET ROOSEVELT
Meet Roosevelt Veterinary Center
Photo Gallery
SERVICES
Lifelong Services
General Wellcare
Vaccinations
Spay and Neuter Services
Dental Care
Diagnostics + Imaging
Surgery
Specialty Services
Boarding + Daycare
Pet Pharmacy
Emergency Care
BOARDING & DAY CARE
Roosevelt Mansion
PATIENT RESOURCES
Appointment Options
Veterinary Telemedicine
Important Forms
Payment Options
Pet Pharmacy Needs
Frequently Asked Questions (FAQs)
Latest Therapeutics
PUPPY & KITTEN PACKAGES
CONTACT US
MEET ROOSEVELT
Meet Roosevelt Veterinary Center
Photo Gallery
SERVICES
Lifelong Services
General Wellcare
Vaccinations
Spay and Neuter Services
Dental Care
Diagnostics + Imaging
Surgery
Specialty Services
Boarding + Daycare
Pet Pharmacy
Emergency Care
BOARDING & DAY CARE
Roosevelt Mansion
PATIENT RESOURCES
Appointment Options
Veterinary Telemedicine
Important Forms
Payment Options
Pet Pharmacy Needs
Frequently Asked Questions (FAQs)
Latest Therapeutics
PUPPY & KITTEN PACKAGES
CONTACT US
Roosevelt Mansion
Dog Boarding Application Form
Please complete the Roosevelt Mansion Dog Boarding Application as a first step in bringing your dog to board with us.
Thank you for your interest in the Roosevelt Mansion.
We look forward to meeting you and your dog!
Please enable JavaScript in your browser to complete this form.
OWNER / GUARDIAN INFORMATION
Owner/Guardian's Name
*
First
Last
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mobile Phone
*
Home Phone
Email
*
EMERGENCY CONTACT
*
First
Last
Please indicate whom we would contact in case of an emergency, if we could not reach you.
Emergency Contact Phone Number:
*
Relationship to you:
*
PET'S VETERINARIAN INFORMATION
Veterinarian Name (full)
*
First
Last
Name of Veterinarian's Clinic:
Please fill in full business name of veterinary clinic.
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Veterinarian's Phone Number
Please use the most direct phone contact to your veterinarian.
How did you hear about Roosevelt Mansion Pet Boarding and Day Care?
PET GUEST INFORMATION
Dog's Name:
*
Primary Breed:
*
Weight:
*
Color:
*
Age / Birth Date:
*
Check those elements that apply:
*
Male
Female
Spayed
Neutered
Unaltered (Intact)
Has your dog ever attended a daycare or boarding facility in the past?
*
Yes
No
Has your dog ever been to a dog park?
*
Yes
No
Has your dog ever bitten another person or another dog?
*
Yes
No
If Yes, please explain the situation:
MEDICAL HISTORY
Is your dog currently taking any medications?
*
Yes
No
NOTE: IF YOU CHECKED YES, YOU WILL NEED TO FILL OUT AND SIGN A MEDICATION ADMINISTRATION FORM FOR EACH PET.
Has your dog been ill in the last 30 days?
*
Yes
No
Is your dog displaying any symptoms, such as sneezing, coughing, or upset stomach?
*
Yes
No
If yes, please explain the symptoms:
Does your dog have any previous or current injuries, physical problems or health concerns, including allergies?
*
Yes
No
If yes, please explain:
Does your dog have any physical restrictions while playing, or sensitive area on the body?
*
Yes
No
If yes, please explain:
VACCINATIONS
Please list the current expiration dates for the following vaccinations: (front desk may complete once they’ve received proof of current vaccinations). Bordatella vaccination must be administered at least 7 days prior to any services at The Roosevelt Mansion; 3 days for nasal vaccination.
Select those that apply:
*
Rabies
Bordatella
DHLPP
K9 Flu
IPE (Negative stool sample)
Is your dog currently on a flea preventative medication? (Required for all guests)
*
Yes
No
Name of preventative brand:
*
Last date preventative was administered:
*
VERIFICATION
I, the undersigned, hereby acknowledge and agree that all the information in this application is complete and accurate to the best of my knowledge. I further attest that if I am not the sole owner or representative of the dog subject to this application that my signature is sufficient to enter into this application for and on behalf of any owner or representative.
Date
*
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YYYY
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Signature
*
Clear Signature
Please use your cursor to sign here.
Type name
*
First
Last
Please type name if you cannot sign.
Submit