Intake Form


Pet Parent Info

Name

E-mail

Phone

Emergency Contact & Phone

Address

City

Post Code

Basic Information and Medical History

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

Dietary Information

Current food brand?

Please list any dietary restrictions.

Authorization

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

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