Diamond Dog House
1712 Ellen Road, Richmond VA 23230
Phone (804) 254-4101, Fax (804) 200-5621

Information Form

Dog’s Name:______Breed:______Sex:______

Description:______Age:______Approx. Birthdate______

Owner’s Name(s):______

Address:______City/State/Zip:______

Home Phone:______Cell Phone:______

Work Phone:______Other Phone:______

Email Address:______Emergency Contact:______

How did you hear about Diamond Dog House? ______

Veterinarian’s Name:______Hospital:______

Veterinarian’s Phone:______Address:______

IN THE EVENT OF AN EMERGENCY, DIAMOND DOG HOUSE HAS PERMISSION TO TRANSPORT ______TO THE ABOVE VET (OR CLOSEST RELIABLE VET) IF NECESSARY.

Payment arrangements are to be made between the owner and veterinarian in advance.

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Owner’s Signature Date

Certification of Health and Temperament

  1. I understand that I am solely responsible for any harm or damage caused by my dog(s) while he/she is attending Diamond Dog House.
  2. I understand and agree that in admitting my dogs(s), Diamond Dog House has relied on my representation that my dog(s) is/are in good health and have not harmed or shown aggressing or threating behavior towards any person or any other dog.
  3. I understand and agree that Diamond Dog House and their staff will not be liable for any problems that develop provided reasonable care and precautions are followed, and I hereby release them of any liability of any kind whatsoever.
  4. I understand and agree that any problems that develop with my dog(s) will be treated as deemed best by the staff of Diamond Dog House, in their sole discretion, and that I assume full financial responsibility for any and all expenses involved.
  5. I certify that I have attached a copy of vaccination history from the veterinarian. Vaccination certificate must have veterinarian’s name, address and phone number printed on it.
  6. Diamond Dog House reserves the right to refuse admittance to any dog that does not meet the health and temperament requirements.

Please give a brief history on your dog so we might better understand him or her.

______

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I ______(print name) certify that I have read and understand the rules and regulation and accept all the terms, conditions, and statements of this agreement.

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Signature of owner Today’s Date

Welcome to Diamond Dog House!!!!!