Intake Form

K9 Parent's Information

K9 Parent's Full Name (First,Last)

Address

Phone number

Email

Emergency contact if owner cannot be reached

Full Name (First, Last)

Phone number

K9's Information

Fur-baby's name

Breed

Age

Birth date

Month

Day

Year

Gender

Female

Male

Is your fur-baby

Spayed

Neutered

Intact

Color / Special marks

Weight

lb

kg

Is your dog a rescue?

Yes

No

If so, how long have you had your fur baby?

House trained?

Yes

No

Pee-pads

Medical Information

Veterinarian's name

Veterinary clinic name

Phone number

Veterinary clinic address

Vaccinations

Vaccination list

Proof of vaccinations

Flea / Tick prevention

Name of product

Proof of product

List of allergies

Medical conditions

Current medications

Special dietary / feeding instructions

Special requests or special supervision (if any)

Is Kate K9 Care allowed to offer treats?

Yes

No

Has your dog been exposed to any contagious illnesses in the last 30 days?

Yes

No

Is your dog currently under quarantine or isolation?

Yes

No

Any Special Requests or Instructions

I confirm that the information provided on this Intake Form, is true and accurate to the best of my knowledge

I have received and read the policy provided by Kate’s K9 Care

By clicking on the SUBMIT button, I am accepting all terms and conditions as described in the Policy Statement.