Owner
*
First Name
Last Name
Spouse/Other Owner
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone (Primary Contact)
*
Country
(###)
###
####
Cell Phone (Primary Contact)
*
Country
(###)
###
####
Secondary Contact
(###)
###
####
Email Address
*
Pet's Name
*
First Name
Last Name
Pet's Breed
*
Birthday
*
MM
DD
YYYY
Weight
*
Color
*
Sex
Male
Female
Not spayed/neutered (required at 6+months)
*
Veterinary Hospital
*
Veterinary Phone Number
*
Country
(###)
###
####
Veterinary Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Vaccinations
*
Owner/guardian is required to provide proof of current Rabies, Bordetella, DHLPP and Influenza vaccinations as well as a fecal examination by a licensed veterinarian.
Emergency Contact
*
First Name
Last Name
Emergency Contact Relationship to Owner
*
Emergency Contact Phone Number
*
Country
(###)
###
####
Emergency Contact Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How Did You Hear About Us?
*
If You Were Referred, Please List by Who
Have You Ever Used Doggy Day Care or boarding Services at Another Facility? If so, Where?
*
What Are Your primary Reasons for Bringing Your Pet to Uptown Play Day?
*
Which Services Are You Looking For?
*
How Long Have You Had Your Pet?
*
Is there any person, type of dog, or situation your pet is uncomfortable with? Please state No or Yes. If Yes, please describe
*
Has your pet ever growled at or bitten another person or dog? Please state No or Yes. If Yes, please describe
*
Can you take a food item away from your pet without him/her growling? Please State Yes or No.
*
Will your pet readily share toys with other dogs? Please state No or Yes. If No, please describe
*
Has your pet ever jumped a fence or barrier? Please State Yes or No
*
Are there any areas that your pet does not like to be touched? Please state No or Yes. If Yes, please describe
*
Does your pet play well with dogs of all sizes? Please state No or Yes. If No, please describe
*
Is your pet afraid of thunderstorms? Please state No or Yes. If Yes, please describe how we can help
*
Are there any restrictions that should be placed on your pet’s activities? Please state No or Yes. If Yes, please describe
*
Is it okay to give your pet treats? Please state No or Yes.
*
Does your pet have any allergies or medical conditions? Please state No or Yes. If Yes, please list which medications are used to help.
*
Please state name of medication, When it is given (Morning, Afternoon, Evening) & Quantity.
Please state name of medication, When it is given (Morning, Afternoon, Evening) & Quantity.
Please state name of medication, When it is given (Morning, Afternoon, Evening) & Quantity.
Please state name of food given, When it is given (Morning, Afternoon, Evening) & Quantity.
*
Person authorized to pick up/drop off the pet
*
Is there anything else we should know/need to know about your pet?
*
AUTHORIZATION
*
I, the undersigned, hereby acknowledge and agree that all the information provided in this application is complete and accurate to the best of my knowledge. I consent to Uptown Veterinary Hospital, LLC and any related entity’s use of such information for all lawful business purposes which may include, but are not limited to, for example, providing Uptown Veterinary Hospital, LLC services to you, operating the Uptown Veterinary Hospital, LLC business, and using data that includes information about you and your pet for marketing and other purposes. I further acknowledge and agree that I have read, understand and agree to all the terms and conditions contained in the Pet Release, Waiver of Liability, Assumption of Risk and Indemnification Agreement, as they may be amended from time to time, which are attached and fully incorporated into this application by reference. I hereby execute this Application and the Agreement for my pet, myself and my heirs, successors, representatives and assigns. I further attest that if I am not the owner or sole owner of the pet(s) for whom this Application has been completed, my signature is sufficient to enter into this Agreement for and on behalf of any other owner or representative. If signing electronically, I hereby agree that my signature will be deemed an original and take the place of my wet-ink signature. If signing in ink, I hereby agree that a true and correct copy of this document may be produced in lieu of the original Application. Should a copy be produced, I understand that it is legally enforceable and does not affect that terms of the Application in any way. By signing the Application, I acknowledge and agree that my pet(s) will be commingling with pets from other families which in the care of Uptown Veterinary Hospital, LLC.
If you agree to these terms, please sign Name & Date below
