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Pet Intake And Emergency -Form Fill

Section One
Q1

Name

First Name
Q2

Name

Last Name
Q3

Address

Street Address
Q4

Address

Street Address Line 2
Q5

Address

City
Q6

Address

State / Province
Q7

Address

Postal / Zip Code
Q8

Email
Q9

Phone Number
Q10

While I am out of town, I prefer to be contacted by
Q11

What dates will you need me?
Q12

Pet 1: name, age, species, and breed
Q13

Pet 2: name, age, species, and breed
Q14

Pet 3: name, age, species, and breed
Q15

Pet 4: name, age, species, and breed
Q16

Pet 5: name, age, species, and breed
Q17

Does your dog have any medical problems (seizures, painful conditions, etc.)?
Q18

If yes, please list them and explain any accommodations or support I should provide them.
Q19

Is your pet on any medications that I will need to administer?
Q20

If yes, please provide the medication(s), dose, and when and how to administer
Q21

What is your pet's feeding schedule, and routine? (please include food type, quantity and any additional instructions)
Q22

Please list any food restriction or known allergies
Q23

Where does your pet sleep?
Q24

Where does your pet stay when you are not at home?
Q25

If your pet needs to be crated or confined, how do they react?
Q26

Please describe your pet's exercise needs
Q27

Does your pert have any of the following behavior concerns (check all that apply)
Q28

Please describe in more detain the behaviors you selected above, and how you manage them
Q29

Any other behavioral quirks or concerns I should be aware of?
Q30

Describe a typical 24 hour day for your pet(s)?
Q31

Are there any other tasks you need me to do (ie. watering plants, putting out trash bins)
Q32

What should I do the event of an emergency requiring veterinary care? (see emergency policy below for more information)
Q33

What is the best phone number to reach you at, in case of an emergency?
Q34

What is the name of your primary Vet or Vet Clinic?
Q35

Primary Veterinarian's Address
Q36

Primary Veterinarian's Address

Street Address
Q37

Primary Veterinarian's Address

Street Address Line 2
Q38

Primary Veterinarian's Address

City
Q39

Primary Veterinarian's Address

State / Province
Q40

Primary Veterinarian's Address

Postal / Zip Code
Q41

Does your primary veterinarian have 24h emergency hours?
Q42

If No, please list the name, and number of closest 24-hour Emergency vet
Q43

Secondary Contact: In the event that you cannot be reached, Is there someone I can contact for additional support?

First Name
Q44

Secondary Contact: In the event that you cannot be reached, Is there someone I can contact for additional support?

Last Name
Q45

Secondary Contact Phone Number
Q46

Relationship to you
Q47

{Pet sitter's Name} will endeavor to create as safe an environment as possible for the care and training of my animal(s) and will offer only sound, safe, and responsible training and training instructions. However, I recognize that {Pet sitter's Name} is not responsible for any unintentional errors, omissions, or incorrect assertions. I understand that the recommendation of any other product or service is not a guarantee of my satisfaction with that product or service. Further, I am and will remain responsible for the actions of my animal(s) at all times and I hereby agree to indemnify and hold harmless {Pet sitter's Name} of any and all claims of injury, expense, costs, or damages caused by the actions of my animal(s) while under {Pet sitter's Name} care, instruction or control and under my own care as a result of following training instructions. I have been told by {Pet sitter's Name} and understand the inherent risks of owning an animal(s) , including but not limited to the risk of animal bites to myself or others. Emergency Care: In the event that I cannot be reached, {Pet sitter's Name} has my permission to react to a situation as she deems appropriate, and or necessary for the health and safety of my animal(s), herself, or others, and that I am responsible for compensating {Pet sitter's Name} for any monetary charges made for items and or services including but not limited to, vet bills, pet food, or human medical attention. Payment Policy: For new clients, a 25% deposit is due upon booking, the remainder of the payment for services is due 24 hours before the start of pet sitting. I except cash checks, or Venmo. Cancellation Policy: We appreciate cancellation notice as far in advance as possible. To avoid being charged, a 72-hour notice is required. Cancelations within the 72-hour window result in the loss of your 25% deposit. Exceptions will be addressed on a case by case basis. By checking the box below, I agree to and accept the above policies.