FB LP Form AquaPups Charlotte Client Intake And Information

Name*

First NameLast Name

E-mail*

example@example.com

Mobile Phone*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Other Guardian

First NameLast Name

Other Guardian Phone

Please enter a valid phone number.

Do we have your permission to add you to our AquaPups newsletter mailing list? i.e.: monthly specials, holiday parties, fundraisers, contests/game days, etc. (Note: AquaPups does not share or sell your contact information. All information is confidential.)*

YesNo

Let us know your preferred method of contact for appointment reminders.*

EmailText MessageMobile PhoneAlternative Phone

How did you hear about us?

If a friend, who should we thank?

If another vet, what is their name?

If another dog healthcare provider, what is their name?

If a promotion, which promotion?

If a web search, what search term did you use?

Pet Name #1*

Breed*

Date of Birth*

Sex*

MaleFemale

Spayed or Neutered*

YesNo

Name of Primary Veterinary Practice*

Primary Veterinary Practice Phone Number*

Please enter a valid phone number.

Current Medications

Does your dog have any preexisting condition(s) that we should be aware of, such as recent surgery, injuries, treatment, illness, or have a need for daily medication?

YesNo

If yes, list details.

Has your dog harmed any person/dog or shown aggressive behavior towards any person/dog?

YesNo

If yes, list details.

Do you need to add another dog?

YesNo

Pet Name #2*

Breed*

Date of Birth*

Sex*

MaleFemale

Spayed or Neutered*

YesNo

Name of Primary Veterinary Practice*

Primary Veterinary Practice Phone Number*

Please enter a valid phone number.

Current Medications

Does your dog have any preexisting condition(s) that we should be aware of, such as recent surgery, injuries, treatment, illness, or have a need for daily medication?

YesNo

If yes, list details.

Has your dog harmed any person/dog or shown aggressive behavior towards any person/dog?

YesNo

If yes, list details.

Do you need to add another dog?

YesNo

Pet Name #3*

Breed*

Date of Birth*

Sex*

MaleFemale

Spayed or Neutered*

YesNo

Name of Primary Veterinary Practice*

Primary Veterinary Practice Phone Number*

Please enter a valid phone number.

Current Medications

Does your dog have any preexisting condition(s) that we should be aware of, such as recent surgery, injuries, treatment, illness, or have a need for daily medication?

YesNo

If yes, list details.

Has your dog harmed any person/dog or shown aggressive behavior towards any person/dog?

YesNo

If yes, list details.

Do you need to add another dog?

YesNo

Pet Name #4*

Breed*

Date of Birth*

Sex*

MaleFemale

Spayed or Neutered*

YesNo

Name of Primary Veterinary Practice*

Primary Veterinary Practice Phone Number*

Please enter a valid phone number.

Current Medications

Does your dog have any preexisting condition(s) that we should be aware of, such as recent surgery, injuries, treatment, illness, or have a need for daily medication?

YesNo

If yes, list details.

Has your dog harmed any person/dog or shown aggressive behavior towards any person/dog?

YesNo

If yes, list details.

Liability Agreement: Please check each line to indicate you have read and understand the information provided.

I understand and agree that, in admitting my dog to the use of its facility, AquaPups has relied on my representation that my dog is in good health or I have disclosed any known health issues.I have documented any issues in the past of harm, aggression, or threatening behavior towards any person or any other dog.I understand and agree that AquaPups, its staff and volunteers, will not be liable for any problems that arise out of my or my dog’s use of AquaPups’ facilities and I hereby release them from liability of any kind whatsoever in regards to my dog(s) attendance and participation at AquaPupsI understand that I am solely responsible for any harm caused by my dog(s) while my dog is utilizing the facilities of AquaPups. This includes any harm to persons and/or other dogs as well as to the physical property of AquaPups.I understand and agree that any problems that develop with my dog will be treated as deemed best by the staff and volunteers of AquaPups, in their sole discretion. I assume full financial responsibility for any and all expenses involved including injuries to persons and/or dogs, and damages to the facility.I understand that if an injury caused by my dog and to my dog will only be treated if it is considered to be of a serious nature as determined by AquaPups staff in their sole discretion. In the event that treatment is administered, I accept full responsibility for financial obligation of treatment to my dog and any dog injured as a result of my dog’s behavior.I understand that I am responsible for paying 100% of the cost of a scheduled appointment if I cancel with less than a 24-hour notice.

I grant to AquaPups, its representatives, and employees the right to take photographs of me and my dog in connection with any AquaPups services. I authorize AquaPups, its assigns, and transferees to copyright, use, and publish the same in print and/or electronically. I agree that AquaPups may use such photographs of me with or without my name and for any lawful purpose including, for example, such purposes as publicity, illustration, advertising, and web content.

YesNo

I agree that there are inherent risks to me associated with the use of the AquaPups facilities arising out of or associated with use and conditions such as swimming, wet floors, exercise mats, and other dogs. In consideration for AquaPups granting me permission to use these facilities, I agree to release AquaPups from liability arising out of or associated with such permissive arise of the AquaPups facilities. I certify that I have read and understand this Agreement, and that the information set forth above is true and correct. I agree to accept all the terms, conditions, and statements of this agreement, and any rules or regulations of AquaPups.

Date

AquaPups Pool Rules

AquaPups pool is recreational use only, NOT for therapy. Dogs with recent surgery/injuries or other health concerns will be asked to leave.
You must check-in with an AquaPups staff member before swimming your dog(s). Do NOT enter the pool area without permission from an AquaPups staff member.
All dogs MUST BE ON LEASH when outside the pool area. Retractable leashes are NOT permitted.
You are totally and completely responsible for the care, conduct, and actions of your dog(s). This includes your dog(s)’s interactions with other dogs.
Please attend to your dog(s) at ALL times.
Children must always be under parental control and may NOT get into the pool. Only AquaPups staff members are allowed in the pool.
AquaPups personnel will ask overly aggressive dogs and/or owners either to take a break from swimming their dog(s) or to leave the premises. If your dog is cranky and/or has a big personality, please ask for assistance from an AquaPups staff member; your dog may need to do Private Swim sessions.
Incontinent dogs are NOT permitted in the pool at any time for health reasons.
No throwing and/or pushing dogs into the pool.
No running on the pool deck.
Walk your dog(s) prior to entering the facility at each visit. You must walk your dog(s) every 10-15mins while swimming. Repeated in-pool or pool-area accidents may result in your pup(s) getting banned from the AquaPups pool.
During Group Swim hours, the pool is available on a first-come-first-served basis, regardless of Group Swim appointments on the schedule at any time.
The AquaPups pool and ramp are restricted to AquaPups personnel, clients, and dogs.
The pool deck is NOT for play. If your dog is disruptive you will be asked to leave.
Please make sure your dog does not obstruct the ramp for other dogs; prevent them from standing on the ramp for extended periods of time.
No food allowed on pool deck.

To verify that you have read and agreed to these rules, please sign below:

If you do not receive an email from us confirming that we got the intake form to please call us: 704-396-5702.

Please verify that you are human*

AquaPups Charlotte Client Intake & Information Form