Owners Name: *

Street:

Suite, Unit, Apt:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

E-mail Address: *

Emergency Phone:

Emergency Contact Person:

Dates of Services Requested: *

Services Requested: *

Pet's Name:

Breed / Or Combination:

Color(s):

Sex:

Spayed or Neutered? Select Spayed Neutered

Type of Pet:

Date of Birth:

Weight:

Health Problems:

Vet:

PA State Dog License # (required unless dog has an out of state address):

Medications (must be labeled pet’s name/ dosage):

Vaccination Record (give date - must be current):

DHLP-P:

Bordetella:

Rabies:

Feline Leukemia:

CCRP:

Special Instructions:

Labeled Possessions:

Regular Brand of Food:

Amount:

Time of Meal(s):

What is your pet’s favorite toy?:

Pet’s favorite past time?:

How long is your pet alone?:

Pet’s exercise schedule?:

Does your pet live with:

Children

Dog

Cat

Other

Only with owner

Is your pet afraid of:

Loud Noises

Thunder / Lightning

Other Animals

Men

Women

List of Other Fears

Has your pet ever shown aggressive behavior towards:

Humans

Animals

Please explain:

Has your pet ever bitten anyone or another animal:

Details:

Has your pet ever shown any destructive behavior:

Explain: