Health Information / Contact Information

Name of dog:__________________ Breed:___________________  Age:______ Sex:__ M __ F

Colour:____________________ Weight:_________________ Date of Birth:________________

Owner's Name:__________________________     Phone #:____________________________

Address:______________________________________________________________________

City:__________________________________      Postal Code:__________________________

Cell #: ________________________________     Business #:__________________________

Check one of the following:

___Neutered male                            ___Spayed Female                          ___Under 8 months old

*all females over the age of 8 months must be spayed to participate in the daycare program

*unneutered males may be allowed to participate in daycare on a case by case basis

Method of flea control_____________________*all dogs must be on a flea prevention program

We recommend treating your dog for fleas year round if they will be around other animals.

Date of vaccinations

DHLPP(DA2PP)_______________ Rabies______________________ Bordetella______________

*we require proof of these vaccinations. Required yearly.

Puppies must have a minimum of their second set of shots to participate in any of our programs.

Veterinarian Name/Clinic:________________________________________________________

 

Phone #:________________________________City:_________________________________

*By submitting this form you authorize Paws for Love Inc. to obtain medical /vaccination records for your pet from the veterinarian listed above and you hereby authorize your veterinarian to release these records to Paws for Love Inc.

Emergency Contact (other than owner!

Name: ________________________________  Phone #: ______________________________

Address: _______________________________ Relationship to you: _____________________

Alternate Contact:________________________ Phone #:______________________________

Is your dog on any type of medication? _____________________________________________

Does your dog have any allergies?_________________________________________________

Any other health / medical information we should know about?___________________________

Signature__________________________________ Date ______________________________