Full Application All fields marked with an asterisk (*) are required Owner’s Contact Information First Name* Last Name* Street Address Line 1* Street Address Line 2 Town/City* State* ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code* Home Phone** Work Phone** Cell Phone** ** At least 1 phone number required Fax Your Email* Alternate/Emergency Contact Information: First Name Last Name Street Address Line 1 Street Address Line 2 Town/City State ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Home Phone Work Phone Cell Phone Fax Email Veterinarian Information: Name* Street Address* Town/City* State* ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code* Phone* Fax How long a patient? Pet Information Name* Age (years)* ---123456789101112131415161718192021222324252627282930 Birthday Sex* MaleFemale Spayed/Neutered* YesNo Breed* Pet Color* Weight (lbs)* ---123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200 Microchip* YesNo Microchip Number General Information Is your dog allowed to have treats?* YesNo What type? What kind of toys does your dog like to play with? What special commands does your dog respond to? Bathroom Command Quiet Command Play Command Does your dog need to be fed while caring for him/her?* YesNo What time? (You will need to provide their food and any instructions)* Does any person in your houshold have a peanut allergy?* YesNo If yes, can we still use peanut products with your dog? Yes Health Information Is your dog on flea/tick preventative?* YesNo Name* Any known health concerns to be aware of?* YesNo Describe* Does your dog have any medical needs which restrict his/her activities?* YesNo Describe* Is your dog currently on any medication?* YesNo Describe* Will your dog need medication while we are caring for him/her?* YesNo Describe Does your dog have any allergies?* YesNo Describe* Does your dog like to be brushed? Yes How Often Will your dog need to have his/her nails trimmed? Yes Special Instructions Does your dog have any sensitive or painful areas on his/her body?* YesNo Describe* Dog Temperament Has your dog ever shown signs of aggression?* YesNo what was the cause? (E.g. toys, food, other dogs, people)* How does your dog react to strangers?* Does your dog fear or dislike any specific types of people?* YesNo Describe* Does your dog have a tendency of escaping structures? (I.e. fences, kennels, crates)* YesNo Describe* Does your dog have any known behavioral problems?* YesNo Describe* Is your dog frightened of anything?* YesNo Describe* How does your dog react to other dogs?* How well does your dog walk on a leash?* How does your dog respond/react to being put in a crate?* Please describe your dog’s overall temperament* What are your preferred time(s)/day(s) of attendance? How did you hear about us? Upon completion of this application, you must also present a current rabies certificate and a health certificate from your veterinarian which shows that your dog is completely up to date on all vaccines including: Distemper, kennel cough and Bordatella. It is highly recommended that your pet has the flu vaccine.
