Client Information Form
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Client Information
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Emergency Contact
Primary Contact
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship to Client
Secondary Contact
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship to Client
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Pet Information
Rows
Name
Dog/Cat
Male/Female
Weight
Age
Neutered/Spayed
Pet 1
Pet 2
Pet 3
Pet 4
Pet 5
Pet 6
Persons authorized to pick up or drop off my animals
ALL animals being boarded are required to be current on vaccines. Please verify the vaccines that animals have been given.
Dogs - DHLPP/DHPP
Dogs - Rabies
Dogs - Bordetella
Dogs - Influenza (Not required to board, but HIGHLY recommended)
Cats - Rabies
Cats - FVRCP
UBR has a strict “No Flea” policy. Any pet found withfleas will be charged $20 for a flea bath and a $25 cleaning expense fee.
Agree
Disagree
Able to provided veterinary proof of vaccines
Yes
No
Vaccine Records
Veterinarian Hospital/Clinic Name
Primary Veterinarian
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Animal Medication. Medications must be in orginal package with animal's name on it with dosage information.
Will you provided food
Yes
No
How many cup(s) do you feed a day?
Any special feeding instructions?
How often do you feed?
AM
PM
Both
Free Feed
Other
Food Alergies?
Is your animal pet friendly?
Yes
No
Can your dog be socialized with "new" dogs?
Yes
No
Does your animal have any aggression issues that we should know about?
Anything else we should know about your babies?
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Fees Schedule and Authorization
You are chargedfor the day you drop your animal off regardless of the time. You are not charged for the day of departureas long as you pick up by 12 noon. Youwill be charged a Day Camp Fee of $30 a day& $15 for each additional dog if picked up after 12 noon that day.
Agree
Disagree
I give my permission to the staff of Urban Mutt Retreat to board and administer vaccines, medications and/or treatments deemed necessary for the health, safety or wellbeing of my animals while under the supervision of Urban Mutt Retreat. I understand every effort will be made to contact me if an emergency occurs. However, if I cannot be reached, medical treatment medical treatment will be provided at my expense.
Agree
Disagree
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