Vetcetera Vet

                                                                Vetcetera Animal Hospital’s
                                             Doggie Daytime Socialization - Enrolment Form

Owner Information:

Name: _________________________________________________________

Secondary name: _________________________________________________

Address: ________________________________________________________

Home Phone: ____________ Work Phone: ____________Cell: _____________

Email: ___________________________________________________________

Pet Information:

Name: ________________________________ Sex: Male_____ Female______
Is your pet spayed or neutered? Yes_____ No_____ If not, do you plan to? Yes_____ No_____
Breed_____________________________ Date of Birth: ___________ mm/dd/yy
Does your dog have any medical conditions? Yes_____ No_____
If yes, please specify: ____________________________________________________
Is your dog currently taking any medications? Yes_____ No_____
If yes, please list: ________________________________________________________
Does your pet have any allergies/sensitivities? Yes_____ No_____
If yes, please list: ________________________________________________________
Is your pet currently a client of Vetcetera Animal Hospital? Yes______ No _____
If not, please list your current veterinary hospital name and phone number:

Emergency Information:

Please provide us with an emergency contact person and phone number other than yourself. In the event of an emergency, this person is able and willing to make decisions regarding your pet and/or transport your pet to your regular veterinarian if needed if you are unreachable for any reason.

Name: ___________________________ Relationship to you: _______________
Phone: ________________ Cell: _______________ work: _________________
If Vetcetera Animal Hospital is unable to contact the owner or the designated emergency contact person, I authorize Vetcetera Animal Hospital to provide emergency veterinary care at my expense. Payment for these services will be billed at the time of pick up.

Vaccinations:

For your dog’s protection and that of the other dogs visiting our Doggie Socialization Area, Vetcetera Animal hospital requires that all dogs entering Doggie Socialization be current on vaccinations. A vaccination certificate from your veterinarian will be required prior to entry.
DA2PP (Distemper) vaccination is required 2 years in a row, then once every 3rd year.
Date of last vaccination: _________________________________mm/dd/yy
Bordetella (Kennel Cough) vaccination is required annually.
Date of last vaccination: _________________________________mm/dd/yy
Rabies vaccination is required 2 years in a row, then once every 3rd year.
Date of last vaccination: _________________________________mm/dd/yy
Office use only: Vaccination verified □ Vaccine recall logged for _____________mm/dd/yy □

Parasite Control:

All pets must be on parasite prevention for intestinal parasites (worms) and fleas. Due to the high concentration of Deer Ticks in this area and the increased risk of Lyme disease from those ticks, we strongly recommend tick prevention be in place as well.
We reserve the right to treat your pet for fleas, worms and/or ticks at any time, at your expense, if we discover any of these parasites while your pet is in our care. The cost will depend on the size of your dog.
Please specify which parasite prevention product your pet is on and supply proof from your veterinarian. In order for these to be kept current, they need to be given monthly, year round.

Sentinel (fleas/worms) Interceptor (worms) Revolution (ticks-limited/fleas/worms)
Advantage (fleas) Advantix (ticks/fleas) Advantage Multi (fleas/worms)
Lopatol (worms) Drontal Other___________________
Date last given: _________________________

If you do not use tick prevention (Advantix/Preventic) please read and sign the following:
The staff of Vetcetera Animal Hospital has informed me of the danger of ticks and tick borne diseases in this area. I understand the danger to my pet of these parasites and diseases. I decline tick prevention at this time. Vetcetera Animal Hospital will not be responsible in any way if my pet contracts a tick while in their care, nor will they be held responsible ethically or financially, should my pet at any time be diagnosed with any tick borne disease including Lyme Disease
Signed: _______________________________ Date: _____________
Witness: _________________________________________________

Behavior:

Is your dog social with other dogs? Yes No Unsure
Is your dog social with other people? Yes No Unsure
Is your dog housetrained? Yes No
Has your dog attended puppy socialization/dog training? Yes No
If yes please specify: __________________________________________
Has your dog ever been involved in a dog fight? Yes No
If yes please describe and specify damages: __________________________________
______________________________________________________________________
How often should would you like your dog to be taken outside? Every ______ hours.
Does your dog have signals we should be aware of to indicate they need to go outside?
If yes, please specify: ____________________________________________________
Is there anything else you feel we should know about your dog’s behaviour? ____________________________________________________________________________________________________________________________________________

I, _____________________________, as the Owner/Agent of the above-mentioned pet, certify that all information is true and is an accurate representation of my pet.

Sign: ____________________________________ Date: ______________________

Witness: ______________________________________________________________