Owner(s) Date
Address City State Zip
Home Phone Work Phone Cell Phone
Email Address
Emergency Contact Phone
Names of people authorized to drop off/ pick up your dog
Dog Name Breed
Date of Birth Color Weight
Male Neutered Female Spayed Markings
Veterinarian Address
Phone Fax
Immunization Requirements: It is the Owner's responsibility to provide proof of vaccination for each animal coming into THE DOG HOUSE. Dogs that are not up-to-date on their shots will not be allowed in. The following Vaccinations must be administered 5 days or more prior to attendance: Date Given: Distemper Rabies Bordetella (1 year)
OWNER UNDERSTANDS THAT EVEN IF YOUR DOG IS VACCINATED AGAINST CANINE COUGH (BORDETELLA), THERE IS STILL A CHANCE THAT YOUR DOG MAY CONTRACT CANINE COUGH. I AGREE THAT I WILL NOT HOLD THE DOG HOUSE RESPONSIBLE IF MY DOG CONTRACTS CANINE COUGH. (INITIAL)
Name of food Quantity Frequency
Wet Dry Mix Dry mixed with water Allergies
Food restrictions Can He/She have treats? Yes No
Medication Frequency
How did you hear about us?
How long have you had your dog?
Where did you get your dog?
Has your dog ever bitten anyone? Yes No
Is your dog food or toy aggressive? Yes No
If yes, please explain
Has your dog ever been in a large play group before? Yes No
Has your dog ever been to daycare or boarding before? Yes No
If so, when was the last time?
What is your dog's favorite toy?
What is your dog's favorite treat?
Please list any information about your dog that we should know:
