Client Intake Form
Ataraxia has a 3 mile service radius from downtown Grand Rapids. Additional fees may apply.
How did you hear about us?
*
Owner Information:
Name
*
First Name
Last Name
Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number
*
Please enter a valid phone number.
Phone number
Please enter a valid phone number.
Email
*
example@example.com
Emergency contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Pet care group chat?
*
Please Select
YES
NO
General Pet Information:
How many of your pets will we be caring for?
*
Please Select
1
2
3
Pet name:
*
Pet species:
*
Dog, Cat, Fish, etc
Breed:
*
Age:
*
Sex:
*
Pet Health Information:
Any known allergies:
*
Current medications:
*
List all that apply
Medical conditions:
*
List all that apply
Pet Behavioral Information:
Any known behavioral issues or concerns:
*
Any aggression or fear towards certain people, places, or things?
*
Favorite activities or toys?
*
Feeding and Dietary Preferences:
Type of foods:
*
Feeding schedule:
*
Treat preferences:
*
Exercise and Play Preferences:
Daily exercise needs:
*
Favorite activities or games:
*
Pet name (2):
*
Pet species:
*
Dog, Cat, Fish, etc
Breed:
*
Age:
*
Sex:
*
Pet Health Information:
Any known allergies:
*
Current medications:
*
List all that apply
Medical conditions:
*
List all that apply
Pet Behavioral Information:
Any known behavioral issues or concerns:
*
Any aggression or fear towards certain people, places, or things?
*
Favorite activities or toys?
*
Feeding and Dietary Preferences:
Type of foods:
*
Feeding schedule:
*
Treat preferences:
*
Exercise and Play Preferences:
Daily exercise needs:
*
Favorite activities or games:
*
Pet name (3):
*
Pet species:
*
Dog, Cat, Fish, etc
Breed:
*
Age:
*
Sex:
*
Pet Health Information:
Any known allergies:
*
Current medications:
*
List all that apply
Medical conditions:
*
List all that apply
Pet Behavioral Information:
Any known behavioral issues or concerns:
*
Any aggression or fear towards certain people, places, or things?
*
Favorite activities or toys?
*
Feeding and Dietary Preferences:
Type of foods:
*
Feeding schedule:
*
Treat preferences:
*
Exercise and Play Preferences:
Daily exercise needs:
*
Favorite activities or games:
*
Emergency Care Instructions:
Instructions for an emergency:
*
Preferred vet clinic and contact information:
*
Any medications administered in case of an emergency:
*
Any other information that may help me care for your pets:
*
Would you allow us to post photos of your pets on our socials?
*
Please Select
Yes
No
Photo release consent for our socials
Continue
Continue
Should be Empty: