CLIENT INFORMATION

YOUR Name:

Address:

City:

Zip Code:

Home:

Cell:

Work:

E-mail Address:

Alternate E-mail Address:

Were you referred by anyone or ho w did you hear about the LUCKY DOG LOUNGE?  

EMERGENCY CONTACT INFORMATION

Name:

Relation:

Home:

Cell:

Work:

Who besides yourself is authorized to pick-up your pet(s)?

Name:

Phone:

Name:

Phone:

Name:

Phone:                                  

MEDICAL INFORMATION

Veterinarian:

City:

Phone:

Does your pet take any medications?     NO             YES – please list below

Medication:

Directions

Will we be administering?

  NO  YES

  NO  YES

PET INFORMATION

Name:                                                                  

Breed:

Colors:                             

 MALE

 FEMALE

Age & Birthday (or day celebrated):

 INTACT

 ALTERED

Does your dog have ID tags?

License  or Rabies  tag#:                                 

County:

Microchip#:

Where did you get your pet?

How long have you owned you pet?

Brand of flea protection:

Is your dog housebroken?          NO  YES

Does your dog chew on objects?    NO  YES

Does your dog wheeze, cough, exhibit any asthmatic symptoms, or have allergies?        NO  YES                   

IF YES PLEASE EXPLAIN:

Does your dog have any problems with other dogs:    NO  YES

Does your dogs have any issues with children:    NO  YES

Has your dog ever shown aggressive behavior?     NO  YES

Is your dog able to jump over 4 feet?    NO  YES  

Is your dog scared by anything?

  NO  YES

Has your dog ever been abused?

  NO  YES

IF YES TO ANY ABOVE QUESTIONS PLEASE EXPLAIN:

MY DOG IS:   SHY  ð  MELLOW  ð AGGRESSIVE  ð EXCITABLE  ð ACTIVE  ð COUCH POTATO  ð  CONTENT TO BE AROUND OTHERS   ð

MY DOG IS ALLOWED ON FURNITURE AT HOME?   YES ð  NO  ð    but okay at Lucky Dog Lounge  ð

WHAT IS YOUR DOG’S USUAL DAY LIKE?  Feeding times? Amount of time outside?  ETC….

ADDITIONAL INFORMATION THAT YOU WOULD LIKE US TO BE AWARE OF: