Check-in Form

*Vet Name: 

Practice Name:  

*Office Phone:     Office Fax:   

*After Hours Phone:     (include Area Codes)

*Vet Street Address (no PO Boxes)
*Street Address   

Please list at least two people who are likely to be able to reach you in the event of an emergency.    Furthermore, these people will be authorized to MAKE DECISIONS REGARDING EMERGENCY CARE in the unlikely event you cannot be reached, and/or PICK-UP YOUR PET in the event you are unable to do so.  WE CANNOT RELEASE YOUR PET to anyone who is not listed below:

Contact No. 1:   

*Name:     
*Day Phone:         *Evening Phone: 

Contact No. 2:   

Name:   
Day Phone:           Evening Phone: 

*Pet's Name:     *Type:  Dog Cat  

*Breed:    *Color(s):

Approx. date of birth*           *Sex:  Male  Female   *Spayed/Neutered?   No   Yes

MEDICAL CONDITIONS AND HEALTH RECORD:

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Please fill in the following section for DOGS only:

Has your dog ever bitten someone?   Yes No   N/A

If yes, please explain the circumstances 

Does your dog know any basic commands or tricks? Yes No   N/A

If yes, please list  

Please fill in the following section for CATS only:

Does your cat bite?   Yes No   N/A

If yes, please explain the circumstances 

Is your cat declawed? Yes No N/A      If so, how many paws?  

 

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Medical Conditions or Health Concerns: 

Prescriptions: 
Schedule: 

Allergies: 

Digestive or elimination habits or problems we should be aware of: 

We will require a health certificate from your veterinarian upon check-in.

* Immunizations
We require WRITTEN PROOF of the following immunizations from your veterinarian upon check-in.

	Date Given
DOGS AND CATS
RABIES
DISTEMPER
DOGS ONLY
BORDATELLA
PARVOVIRUS
CATS ONLY
FeLV (Feline Leukemis Virus)
FVRCP (Feline Viral Rhinotracheitis, Calicivirus, Panleukopnia)

 Is there anything else you would like us to know:  

When you come to check in, please come prepared with your itinerary and contact information, in the unlikely event that it should become necessary to reach you.