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Medication Authorization Form

Thank you for giving West Chester Pet Resort the opportunity to care for your pet(s). To ensure the best care possible, please fill out this form completely. We’ll reach out with any questions.

Client Name *

Patient Name *

First

Last

Email *

Phone

I understand that West Chester Pet Resort will be administering medication during my pet’s stay. I also understand there is a medication fee for the administration of insulin $5.00/day for diabetic pets. *

I Agree and Understand

All medications (this includes supplements, vitamins, oils, etc.) MUST be in their original prescription bottles/packaging to be accepted for administration -- NO EXCEPTIONS. All pets requiring medication while boarding MUST be checked in NO LATER than 10:30AM. *

I Agree and Understand

Please thoroughly complete the table below to indicate the medication your pet will be given, how much, how often
and the last time the medication was administered. See example below on how to properly complete the medication
information and instructions.

Name of Medication *

Example: Rimadyl 25mg

Amount Given *

How Often *

Last Dosage Given (Date & Time) *

Date

Time

Medical Reason for Medication

Do you have a 2nd medication? *

YES
NO

Name of Medication *

Amount Given *

How Often *

Last Dosage Given (Date & Time) *

Date

Time

Do you have a 3rd medication? *

YES
NO

Name of Medication *

Amount Given *

How Often *

Last Dosage Given (Date & Time) *

Date

Time

Do you have a 4th medication? *

YES
NO

Name of Medication *

Amount Given *

How Often *

Last Dosage Given (Date & Time) *

Date

Time

Do you have a 5th medication? *

YES
NO

Name of Medication *

Amount Given *

How Often *

Last Dosage Given (Date & Time) *

Date

Time

To ensure your pet get's their medication, please let us know the best way to administer medication to them: *

Cheese
Peanut Butter
Pill Pockets
EN Meatball (canned dog/cat food)
Owner Provided
Other

If other please explain:

Special Medication Directions:

Client Authorization *

Clear Signature

Signature

Date *

Phone

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