Date: ______

Pleasant Paws Inn LLC, 9 Hobby Street Pleasantville NY 10570 | Phone: 914-773-2020

Owner Information: Interviewer: ______

Name: ______

Address: ______City:______

State: ______Zip: ______

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

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Dog Information:

Name: ______Breed: ______Sex: M/F

Birthday: ____/_____/______Age: ______Weight: ______Lbs. Spayed/Neutered: Yes or No

Vet Name: ______Vet Phone: (______) ______-______

Vet Address: ______

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Behavior History:

Where did you obtain your dog? ______

If you are your dog’s second owner what is his or her history? ______

Has your dog had formal obedience training? Yes or No

Classes? ______Private/Trainer: ______

Which commands does your dog know? ______

·  Was your dog crate trained? Yes or No

·  Where does he/she sleep at night? Room or Crate Other:______

·  Where does he/she stay when alone? Room or Crate Other:______

·  Is your dog house trained? Yes or No

·  Is your dog leash trained? Yes or No

How do you usually exercise your dog? (Leash, fenced yard, dog parks, etc.) ______

Has your dog tried to jump over or dig under a fence? ______

Does your dog respond to his or her name with distractions? ______

How does your dog behave with other dogs?

On leash? ______

Off leash? ______

How does your dog react to puppies? ______

How does your dog react to other animals? ______

How does your dog behave with people (strangers and children)? ______

Has your dog ever shown teeth, growled, snapped, or bitten a family member or stranger? ______

Is your dog Protective of any of the following? (With dogs, people or both)

Bones: Yes or No Food: Yes or No Water: Yes or No Space: Yes or No

Treats: Yes or No Toys: Yes or No Bed: Yes or No Other: ______

Explain: ______

Does your dog have a fear of specific things or sounds? (Thunderstorms, cars, etc.)? ______

Does your dog have any symptoms of separation anxiety? (Destructive behavior, house soiling, etc.)? ______

Health and Diet:

Diet: ______

How much: ______How often: ______

Are there any foods your dog cannot tolerate? ______

Does your dog have any medical conditions? ______

How often is it treated? ______

Any past surgeries? ______

Grooming:

Does your dog like to be brushed? Yes or No

Does your dog have any sensitive areas? Yes or No

Does your dog have any moles or growth Yes or No Where? ______

Does your dog tolerate nail clipping or grinding? Yes or No Which? ______

Does your dog get groomed regularly? Yes or No

Who is his/her groomer? ______

Pleasant Paws Inn LLC Agreement,

I understand certain “activities” that my dog may participate in, including daycare, boarding, one-on-one play, within the home, involve risk and possible injury, including but not limited to Exposure to parasites, viruses, and other medical conditions, sprains, bites, broken bones, cuts, or death.

I also understand that many potential risks can happen, and agree that the benefits associated with dog socialization outweigh the possible risks, therefore, I hereby voluntarily release, Pleasant Paws Inn LLC and its staff from any and all liability that can happen.

I understand and agree that dogs can play very rough. I understand that it is not uncommon for dogs to get a scratch or a tough of hair missing due to rough play. It is to my knowledge that Pleasant Paws Inn LLC supervises all play sessions and will never put any dog in a dangerous situation. If my dog is ill or injured while at Pleasant Paws Inn, a Pleasant Paws Inn staff will make the effort to reach me via the contact information I have provided. However, if Pleasant Paws Inn is unable to reach me, I consent staff to seek appropriate veterinary care, knowing that Pleasant Paws Inn will not financially be held liable for treatment or any injuries that may occur. I am also aware that I will be billed for any damages my dog may cause to the Inn. I also permit Pleasant Paws Inn to use any photographs of my pet for advertising purposes.

I certify that I have read and understand all the rules and regulations set forth on the above page and that I have read and understand this agreement. I agree to abide by the rules and regulations and accept all the terms, conditions and statements of this agreement.

______(Printed Name)

______(Signature)

______(date)

______

(Pleasant Paws Inn staff signature)

______(date)

Pleasant paws Inn LLC

Health and Temperament Certification

I______hereby certify that my dog is in good health and have not been ill with any communicable diseases in the last thirty days. I further certify that my dog(s) have not harmed or shown any aggressive threatening behavior towards any person or any other dog.

I am aware that the following are required of all dogs at Pleasant Paws Inn

·  Vaccines must be current (DHLPP, Rabies and Bordetella)

·  Copy of current vaccination records (provided by veterinarian)

·  Any Medication with administration instructions (if applicable)

·  All dogs must wear a flat collar with a name tag on it

·  Dogs must bring their own food in a labeled container

·  A Completed Introduction Packet & Signed Agreement Contract

I am also aware that my dog(s) must be on an effective flea and tick control program and free of internal parasites (fecal exam required annually) Heartworm______, Flea and Tick Control______.

(If using Frontline, please do not apply less than 24 hours prior to arrival)

______(Signature)

______(date)

Restrictions

Dog(s) must be:

ü  16 weeks (4 months) of age or older

ü  in good health

ü  Current on their DHLPP, Rabies and Bordetella (kennel cough) vaccines, CIV recommended

ü  On an effective flea and tick control program and free of internal parasites

(Fecal exam required annually)

û  Female dogs “in season” cannot attend

û  Dog-aggressive dogs and/or people aggressive dogs cannot attend

Payments

For dog boarding payment is due upon Drop off. Checkout is at 9:00am if you stay after checkout time, there will be an additional fee of another boarding day.

Checks and Credit card are all acceptable forms of payment.