Vet Wellness Center Green - Pet Parent Info Form

1
Pet Parent Info Sheet
I have read, understand, and signed the release and waiver of liability agreement that remains on file at The Vet Wellness Center of Green.
I also have read and understand the policies and procedures required for my pet to board.
2
Pet Parent First and Last Name* This field is required.
First Name
Last Name
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Email* This field is required.
example@example.com
5
Best number to reach you regarding your pet* This field is required.
6
Do we have permission to leave you a voicemail message?* This field is required.
Yes
No
7
Do we have permission to text you messages and/or updates?* This field is required.
Yes
No
8
Emergency Contact Information* This field is required.
Contact Name
Relation
Phone number
9
Are there additional people authorized to release information about pet to and/or pick-up pet from boarding other than self?* This field is required.
YESNO
10
If yes, please list* This field is required.
Name
Phone
Name
Phone
11
Is your pet a patient of The Veterinary Wellness Center of Green?* This field is required.
Yes
No
12
If no, please give us the name and phone number of your veterinarian and/or clinic* This field is required.
13
The Vet Wellness Center of Green boarding will attempt to contact you if any medical treatment is warranted during your pets stay. Medical treatment can include treatment for: diarrhea, vomiting, anxiety, ear/skin/eye concerns or other emergent situations that rarely arise.

If you are not available, do we have your permission to treat?    *
I authorize additional charges in the amount of    *

Do not proceed with any additional treatments or procedures until I am reached. *
14
Please enter the pre-approved amount you authorize for treatment.* This field is required.
15
I understand this will remain in my pets file and I, the pet parent am responsible for notifying The Veterinary Wellness Center team when changes are necessary.
Name *
Date Date *
16
* This field is required.
Dog’s Name
Breed
Age
Weight
Color
Please Select
Please Select
Male
Female
Sex
Please Select
Please Select
Yes
No
Altered
17
* This field is required.
Please Select
Please Select
Yes
No
Is your pet current on flea prevention?
Name
18
Does your pet have any food or medication allergies/sensitivities?* This field is required.
Yes
No
19
If yes, what are they?* This field is required.
20
Does your pet have any pre-existing conditions such as seizures, torn ACL, Diarrhea?* This field is required.
Yes
No
21
If yes, please give details* This field is required.
22
Does your pet ever eat or destroy non-food objects?* This field is required.
Yes
No
23
Does your pet ever jump fences or try to escape the house or yard?* This field is required.
Yes
No
24
Does your pet have any food aggression?* This field is required.
Yes
No
25
Does your pet have any cage aggression/protection tendencies?* This field is required.
Yes
No
26
Does your pet get along with other animals?* This field is required.
Yes
No
27
Has your pet ever bitten a person or other animal?* This field is required.
Yes
No
28
Does your pet have any fear of thunder/noise?* This field is required.
Yes
No
29
Does your pet do well with baths?* This field is required.
Yes
No
30
Can we give your pet treats other than what you provide?* This field is required.
Yes
No
31
Are there any specific handling directions we need to know regarding your pet? Such as, does not like its feet or ears touched, needs to be hand fed, needs walked on the left side etc.. * This field is required.
32
I understand this will remain in my pets file and I, the pet parent am responsible for notifying The Veterinary Wellness Center team when changes are necessary.
Name *
Date Date *
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