APPLICATION
Owner Information:
Name(s):
Address:
Phone home:
Email:
Emergency Contact(s):
Name:
Phone:
Dog Information:
Name:
Breed:
City, state:
Zip :
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cell :
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Age:
Sex:
Spayed (Neutered) :
Color:
Vaccinations:
Please, provide vaccination record from you veterinary clinic.
Record has to include: Rabies, DHPP , Bordetella and canine influenza
You can fax (310 670 7316), email ([email protected]) or bring with you copy of vaccination
Special needs:
Is our dog(s) currently taking any madication?
If so,please bring detail instraction with dosage and administering precedure.
Are there any medical concern, or disabilities, that we should be aware?
If so, please advise:
Feeding instruction:
If your dog on a special diet? If so, please advise:
Information about your dog(s):
To the best of your knowledge, does your pet have any food/treat/toy aggression
(with people or dogs)? If so, please describe:
Has your dog been exposed to other dogs, people, unfamiliar territory (dog parks, daycare, kennels ...)?
If so, please describe your dog behavior (friendly, shy, aggressive ...):
Any special comments:
How do you found out about us?:
Your Name:
Date:
Dog #2 Information
( please, provide the same information about additional dog(s))
