GENERAL INFORMATION
&
VETERINARIAN APPROVAL
Dog's Name
___________________________Breed_____________________
Description ____________________________________________________
Age ______________Approximate Birth Date ________________
Owner's Name
_________________________________________________
Address ______________________________________________________
City/State Zip _________________________________________________
Home Phone ________________________Work Phone ___________________
Cell Phone __________________________Pager _______________________
Other Emergency Contact __________________________________________
E-Mail Address _________________________________________________
How did you hear about Strictly Dogs? ________________________________
Veterinarian's Name _____________________________________________Veterinarian's Phone Number _______________________________________
Vet's Address _________________________________________________
Vet's Comments on dog's behavior and appropriateness for Day Care __________________________________________________
Dates
Last Physical Exam _______________DHLPPC (or the equivalent) _____________
Rabies Vacc ______________________________1 yr or 3 yr (please circle)
Bordatella _______________________________Spayed/Neutered Y N (circle)
Heartworm Test
_____________________Type of Prevention___________________________
Flea Prevention ______________________________________________
The above medical information is
true to the best of my knowledge
Veterinarian's Signature
_______________________________________________________________
In the event of an emergency Strictly Dogs has my permission (Owner's signature)_____________________to transport (dog's name) _______________________ to my vet (or the closest reliable vet) if necessary.
Payment is expected to Strictly Dogs for any expenses incurred.