| Owner(s) Information |
| First Name: |
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| Last Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Home Phone: |
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| Cell Phone: |
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| Other Phone: |
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| Email: |
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| Emergency Contact Information |
| First Name (Emergency Contact): |
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Last Name
(Emergency Contact): |
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| Phone Number: |
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| Pet # 1 Information |
| Pet Name (1): |
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| Breed (1): |
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| Age (1): |
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| Feeding Amount and Frequency (1): |
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| Medication/Supplement Schedule (1): |
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*If your pet is on insulin, please be sure you have enough syringes and insulin for the duration of your trip. If your pet is taking other oral medications, the bottles must be labeled clearly.
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***If your pet has storm or separation anxiety please have your veterinarian dispense some medication if possible and leave it, with instructions, on the counter***
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| Date of last vaccinations (including Bordetella) (1): |
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| Flea Preventative Given (1): |
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| Heartworm Medication Given (1): |
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| Special Instructions (1): |
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Pet # 2 Information
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| Pet Name (2): |
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| Breed (2): |
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| Age (2): |
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| Feeding Amount and Frequency (2): |
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| Medication/Supplement Schedule (2): |
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*If your pet is on insulin, please be sure you have enough syringes and insulin for the duration of your trip. If your pet is taking other oral medications, please be sure that all bottles are labeled clearly. |
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***If your pet has storm or separation anxiety please have your veterinarian dispense some medication if possible and leave it, with instructions, on the counter*** |
| Date of last vaccinations (including Bordetella) (2): |
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| Flea Preventative Given (2): |
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| Heartworm Medication Given (2): |
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| Special Instructions (2): |
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| Other Information |
| Start Date: |
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| End Date: |
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Keys Given |
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Garage Door Opener Given |
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Alarm Code Given |
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In the event of illness or injury, I give Pam Biagi and/or Pat Ottensmeier permission to seek medical care for my pet. If they cannot reach my vet, I give them permission to take my pet(s) to Crossroads Veterinary Hospital in Woodstock, GA for treatment. I further agree to pay any and all charges incurred for treatment. My pet(s) is (are) on flea prevention and heartworm medication, and are up-to-date on all vaccines, including the Bordetella vaccine for kennel cough. I will provide proof of vaccines at the consultation.
I state that everything above is true to the best of my knowledge. By checking the box to the left, and signing below, I release Pam Biagi, Pat Ottensmeier and their estate of any liability for loss or injury while caring for my pet(s) in my home. I take full responsibility for any and all damages to my home caused by pet(s) or any unforeseen outside events, and will not hold Pam Biagi or Pat Ottensmeier responsible in any way.
*Typing your name below will serve as an electronic signature*
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| Electronic Signature: |
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| Security Code: * |
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| Date: |
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