Name
Phone
Emergency Contact & Phone
Address
City
Post Code
Dog's Name
Breed
Color
Weight
Dog Age
DOB (optional)
Sex
MaleFemale
Spayed/Neutered
YesNo
Veterinarian
Phone
Allergies
Past Injuries
Medications
Medical Conditions
Has your dog ever bitten other people/pets?
YesNo
Does your dog chew - bedding/bowls?
YesNo
Can your dog jump a 6 foot fence?
YesNo
Vaccinations (include dates)
Rabies
DHLPP
Bordetella
Current food brand?
Please list any dietary restrictions.
In case of emergency, or if I am unable to pick up my dogs, I (owner/guardian) authorize A Pampered Pooch Bellevue to release the above referenced dog(s) to the following persons. I understand that no other written authorization from me is required for my dog(s) to be released to one of the persons listed herein. I understand that A Pampered Pooch Bellevue will automatically release my dog(s) to the parties listed on the new client information sheet and who have signed the Pet Release form. I understand that I may revoke any person(s) authorization at any time by completing a new Authorization to Release Dog form.
Dogs Name
Dog Name (2)
Authorized Person(s)
Phone(s):
Owner/Guardian Name(s)
Date:
Special Notes