How Did You Hear About Us : Friend Yellow Pages Email/Newsletter

Client & Canine Application

Required vaccines: Rabies, DHLPP and Bordetella.
Expired vaccines MUST be given at least 48 hours before arrival
Females over the age of 7 months must be spayed.
Intact males over the age of 7 months will be charged $4 daily.

How did you hear about us: FriendYellow PagesEmail/Newsletter

FacebookNewspaper Website/ Search EngineInstagramYelpOther______

Pet Parent Information

1stLast Name: ______First Name:______

2nd Last Name: ______First Name:______

Address: ______Apt/Suite: ______

City: ______State: ______Zip: ______

Home: (_____) _____-______Work: (_____) _____-______Cell: (_____) _____-______

Email: ______
Emergency Contacts
(These individuals may drop off or pick up the Canine, other than the Owner.)

Name: ______Phone Number: (_____) _____ - ______

Credit Card Information

Card Type (circle):Visa Master CardAmerican Express Discover

Card Number: ______

Name on Card: ______

CVV: ______Expiration Date (mm/yy): ______/ ______Zip: ______

I, ______, hereby authorize D.O.G. to charge the credit card indicated herein for any of the following: (a) any outstanding or unpaid balances, which remain unpaid; (b) any emergency medical care that is required at the sole discretion of D.O.G.; (c) any additional services provided to the Canine in connection with the services requested by Owner.
Signature: ______Date: ______

Basic Information & Medical History

Pet #1

Name: ______Breed: ______

Color: ______Gender: M F Spayed/Neutered:Yes No

Age: ______Birthday (mm/dd/yyyy): ______Weight: ______pounds

Vet Clinic: ______Phone Number: (_____) _____ - ______

Allergies? ______Past Injuries? ______

Medications: ______Medical Conditions? ______

Brand of food:______Special dietary needs? ______

Are there any specific behaviors or requirements we need to be aware of? ______

______

Pet #2