Owner Information: Name(s): Home phone:Cell phone:Email address: Employer: Work phone:Emergency contact: PhoneDoes this person have the authority to make decisions if you cannot be reached? Yes No Please list the name and phone number of any person(s) that will be authorized to drop-off and pick-up your pet:Name: Add RemovePhone Add RemoveHow did you hear about us? Daycare Questionaire: (One application per dog please)Pet name: Dog’s birthday MM slash DD slash YYYY Sex: Spayed Neutered How long have they lived with you? Where did you get them? Breeder Shelter Pet store Stray Friend Other Does your dog have any current medical conditions? Yes No If yes, describe briefly:Does your dog take any medication regularly? Yes No If yes, which one(s)?Which flea/tick preventative do you use? Which heartworm prevention do you use? Does your dog have any physical limitations that need our attention? Yes No If yes, please describe Does your dog have any allergies to treats? Yes No If yes, what should we avoid? Has your dog ever attended a daycare before? Yes No Has your dog been to an off-leash dog park before? Yes No How does your dog interact with...Male dogs? Female dogs? Adult dogs? Puppies? Has your dog ever bitten another dog cat person If yes, what happened?If yes, what happened?If yes, what happened?Does your dog do any of the following? Digs Mouthy Toy possessive Jumper Poop eater Barker Shyness Escape artist Chewer Has your dog ever climbed or jumped a fence? Yes No Has your dog ever dug under a fence? Yes No How does your dog react when you take away toys or food?Has your dog had any formal obedience training? Yes No If yes, when?What commands does your dog know? Media Release We enjoy sharing photos and videos of our patients and their families on social media and occasionally on print materials, advertising, and signage for the hospital. By agreeing below, you grant Bartram Trail Veterinary Hospital, its representatives, and employees the right to take photographs and/or videos of your pet, and to copyright, use, and publish the same in print and/or electronically. We appreciate your consent, as well as respect if you choose not to participate. Please select one option below(Required) Bartram Trail Veterinary Hospital may take photos and/or videos of my pet(s) Bartram Trail Veterinary Hospital may NOT take photos and/or videos of my pet(s) Owner SignatureDate MM slash DD slash YYYY Staff signatureDate MM slash DD slash YYYY
