Name: Phone #:

Address: Work Phone #:

City, State, Zip: Cell Phone #:

Email Address:

Who else is authorized to drop off/pick up your pet?

Emergency Instructions:

Emergency Phone #::

Have you notified your vet that we may be bringing your pet in for treatment? Yes No

Where did you hear about us?

PET INFORMATION

Pet's Name: Pet's Breed:

DOB/Age: Sex: Male: Female:

Weight: Color: Spayed / Neutered: Yes No

Is your dog house-broken? Yes No

Comments:

Does your dog respond to basic training commands? Yes No

Comments:

How does your dog get along with other dogs?

How does your dog get along with people?

Has your dog ever used any boarding facility before? Yes No

Comments:

Has your dog ever bitten or been bitten? Yes No

Comments:

MEDICAL INFORMATION

Veterinarian: at Clinic/Hospital

Address: Phone:

Please describe your dog’s general health (include any current medical conditions)

Allergies (if any)

Date of most recent vaccination: DHLPP Rabies Bortadella

Is your dog on flea control? Yes No
Name When due

Current medications and when administered

Date of last veterinary exam

Comments

Microchip number Company:

Daily Routine Information:

Regular food: Brand Quantity in Cups: Treats? Yes No

Feeding times

Instructions

Where does your dog sleep at night? Is your dog crate trained? Yes No

What is your dog’s usual bedtime? When does your dog usually wake up?

How does your dog let you know he/she needs to go outside?

Other Comments:

I certify that the above information is true and correct to the best of my knowledge. Yes No

Date:

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