Cohn Boarding Form
Owner Name
Owner Name
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First
Last
CWID/Bursar ID Number
Phone
Phone
*
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Address
Address
Street Address
Address Line 2
City
State / Province / Region
Select a State
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
Postal / Zip Code
Email
*
Alternate/Emergency Point of Contact
Alternate/Emergency Point of Contact
First
Last
Alternate/Emergency Contact Phone Number
Alternate/Emergency Contact Phone Number
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Animal's Regular Veterinarian
Veterinarian's Phone Number
Veterinarian's Phone Number
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Emergency Veterinary Care Instructions
1. For all health issues - client will be called with the option for Cohn staff to transport pet to VMTH for care OR client to pick up pet and transport to vet of choice. 2. If no answer from call and staff feel health issue is emergent, Cohn staff will transport pet to VMTH at client expense.
Animal's Name
Animal's Name
First
Last
Specie
Specie
Dog
Cat
Other
Other
Breed
Age
Sex
Spayed/Neutered
Spayed/Neutered
Yes
No
Weight
Color/Markings
ID Tag/Microchip/Tatoo Number
Medical Problems (if any)
Regular Medications (drug, dose, frequency)
Feeding Instructions/Special Diets (amount, frequency, etc.)
Other Instructions (bedding, toys, habits, behavior, precautions, etc.)
Upload vaccination records
*
Attach Files
Owner/Agency Certification and Agreement
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Owner/Agency Certification and Agreement
I hereby certify that I am the owner/custodian of the animal identified above, and that the listed animal’s vaccinations are current and must be done by a licensed veterinarian (i.e., DOGS: Rabies and canine distemper, canine adenovirus type 2, canine parainfluenza, & parvovirus vaccination, bordetella; CATS: Rabies and calicivirus, panleukopenia, & rhinotracheitis). The Cohn Facility is a flea and tick controlled environment. In the case of either pest being found on the animal, I authorize appropriate pest control to be applied to the animal listed in Part 2. The Cohn Facility shall attempt to contact the animal’s owner/agent and/or alternate POC in the event that the listed animal becomes sick/injured while at the Cohn Facility. The alternate emergency contact listed above is authorized to act on the owner’s behalf if the owner/agent cannot be contacted. Animals that become sick/injured while at the Cohn Facility will be referred to the Boren Veterinary Medical Teaching Hospital (BVMTH) and/or the animal’s regular veterinarian for treatment as indicated in Part 1 above and the owner/agent agrees to pay for all emergency/clinical veterinary services. The BVMTH will bill the owner’s/agency’s OSU Bursar account if applicable for any emergency/clinical services it provides. I hereby authorize the Cohn Pet Care Facility to bill my OSU Bursar account if applicable for all charges that accrue from the boarding of the animal listed. The Cohn Facility accepts credit card, check, cash, or Bursar as payment at time of service.
Owner/Agency Signature
Draw your signature into the box below.
*
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Full Name
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Date
Date
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