OWNER INFORMATION:

Name:

Street Address:

City/State/Zip Code:

Email Address:

Cell Phone Number:

Work Number:

Home Number:

Date(s) you are looking for Pet Care:

Type of Pet Care you are looking for:

DayCare
Boarding
Pet Sitting at home/apartment

If Pet Sitting at your home/apartment, how many times per day would you like your Pet(s) visited?

Preference of Time(s) For Pet Sitting at home/apartment

Morning
Afternoon
Evening

PET INFORMATION:

Name:

Nickname:

Breed:

Birthdate:

Sex:

Male
Female

Color:

Weight:

Neutered/Spayed?

Yes
No

EMERGENCY CONTACT INFORMATION:

Emergency Contact #1

Name:

Telephone Number(s):

Emergency Contact #2

Name:

Telephone Number(s):

VETERINARY INFORMATION:

Name of Office/Hospital:

Office Phone Number:

Address:

Does your pet have Current Vaccinations for Rabies/Distemper/Bordatella?

Yes
No

If Yes, Do you give permission for Cathy's TLPC to contact your Vet to verify?

Yes
No

If answered NO, proof of current vaccinations must be provided to Cathy's TLPC prior to Registration being accepted for your Pet

What Flea/TIck Medication do you use for your Pet(s)

Date Medication was last administered to your Pet:

Does your pet have any allergies?

Yes
No

If YES, please indicate what the allergies are:

Please List any special instructions we should follow:

Will your pet require any medication while in the Care of Cathy's TLPC?

Yes
No

If YES, please specify what medication(s) and when to administer:

Does your Pet have any Activity Restrictions?

Yes
No

If YES, please list what they are:

What type of food does your Pet eat?

Wet
Dry

Food Brands:

Do you give your dog treats?

Yes
No

If YES, what kind and how often?