Printable form
Educational template — customize terms for your business and seek qualified advice where appropriate. Use your browser's Print or Save as PDF command. Do not send completed private information to this public page.
Owner Information
Full Name:
Phone Number:
Email Address:
Preferred Contact Method (Phone / Text / Email):
Home Address:
City:
State:
ZIP Code:
How did you hear about us?:
Emergency Contact
Full Name:
Relationship:
Primary Phone:
Secondary Phone:
Authorized Persons (may interact with your pet)
Name 1:
Relationship:
Name 2:
Relationship:
Home Access
Entry Method (Key / Lockbox / Code / Garage):
Lockbox Code / Key Location:
Security Alarm Code (if applicable):
Special Entry Instructions:
Veterinarian Information
Veterinary Practice Name:
Veterinarian Name:
Phone Number:
Address:
Emergency Veterinary Clinic Name:
Emergency Clinic Phone Number:
Pet Information (complete one section per pet)
Pet #1
Pet Name:
Species / Breed:
Age:
Weight:
Sex (Male / Female):
Spayed / Neutered?:
Color / Markings:
Microchip #:
Medical Conditions / Allergies:
Current Medications (name, dosage, frequency):
Vaccination Status:
Rabies Tag / License #:
Behavioral Notes (fears, triggers, other pets, strangers):
Feeding Instructions:
Pet #2
Pet Name:
Species / Breed:
Age:
Weight:
Sex (Male / Female):
Spayed / Neutered?:
Color / Markings:
Microchip #:
Medical Conditions / Allergies:
Current Medications (name, dosage, frequency):
Vaccination Status:
Rabies Tag / License #:
Behavioral Notes (fears, triggers, other pets, strangers):
Feeding Instructions:
Service Preferences
Services Requested (Walk / Drop-In / Day Care / Overnight):
Preferred Walk Duration:
Preferred Walk Times:
Preferred Route or Restrictions:
Any Additional Notes or Instructions:
Authorization
By signing below, I confirm that the information provided is accurate and complete. I authorize the care provider to seek emergency veterinary care for my pet(s) if I cannot be reached in a timely manner, and I agree to be responsible for associated costs.
I have read and agree to the provider's Service Agreement and Cancellation Policy.
Authorization & Signature
Owner Signature:
Date:
Provider Signature:
Date: