Owner Information *

Primary Owner

Secondary Owner

Does your residence include any of the following features? *

Select all applicable options

Vehicle Gate Access Code

Designated Parking Spot Number

Pedestrian Gate Access Code

Garage Access Code

Door Access Code

Lock Box Access Code

Alarm System Access Code

Number of Keys Issued

Wi-Fi Network Information

None Provided

Emergency Contact Information *

Emergency Contact

Authorized Release Information

Primary

Secondary

Tertiary

Pet Information *

Name

*

Birthday

*

Breed

Gender *

Male

Female

Unknown

Altered *

Yes

No

Unknown

Microchipped *

Yes

No

Unknown

County Registered *

Yes

No

Unknown

Grooming Services Information *

Professional

Nonprofessional

Owner/Myself

None

Training Services Information *

Professional - Board and Train

Professional - Advanced Obedience

Professional - Basic Obedience

Nonprofessional

Owner/Myself

None

Are they house trained? *

Yes

No

Depends

Unknown

Are they crate trained? *

Yes

No

Depends

Unknown

How many hours can they go between potty breaks? *

< 1

1 - 2

2 - 4

4 - 8

> 8

How many hours can they be left alone? *

< 1

1 - 2

2 - 4

4 - 8

> 8

Are they friendly with people? *

Yes

No

Depends

Unknown

Are they friendly with canines? *

Yes

No

Depends

Unknown

Are they friendly with felines? *

Yes

No

Depends

Unknown

Are they friendly with other animals? *

Excluding canine and feline.

Yes

No

Depends

Unknown

Are they allowed at dog parks? *

Yes

No

Depends

Unknown

Are they allowed outside or on walks? *

Yes

No

Depends

Unknown

Behavioral Concerns *

Check all that apply.

Aggression/Resource Guarding (food, people, animals, etc?)

Anxiety (separation, car rides, veterinarians office, etc?)

Coprophagia

Destructive Chewing (toys, furniture, etc?)

Escape (force gates/doors open, digs, jumps gates/fences, etc?)

Fear (noises, people, other animals, etc?)

Mouthiness (barking, whining, etc?)

Shy

Touch Sensitive

Other

None

Have they had any bite incidents? *

Yes

No

How many incidents in total have they had? *

0

1

2

> 2

Parties Involved?

Check all that apply.

Singular Person

Multiple Persons

Singular Canine

Multiple Canines

Singular Animal - Non-Canine

Multiple Animals - Non-Canine

Other

Were any of the incidents reported in the county(s) where they took place?

Yes

No

How frequently do they eat? *

Once a day

Twice a day

Thrice a day

Grazer

Other

Are there feedings time sensitive? *

Yes

No

Depends

Do they take any medication (prescription/non-prescription/supplements)? *

Yes

No

Depends

Do they have any allergies? *

Yes

No

Unknown

Do they have any medical conditions? *

Yes

No

Veterinarians Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Do you have pet insurance? *

Yes

No

Phone

Country

(###)

###

####

Effective Start Date

MM

DD

YYYY

Effective End Date

MM

DD

YYYY

Bordetella (Kennel Cough) *

Elliott's Pet Care: Required

Yes

No

Borrelia Burgdorferi (Lyme Disease) *

Elliott's Pet Care: Recommended

Yes

No

Canine Adenovirus (CAV-2) *

Elliott's Pet Care: Required

Yes

No

Canine Coronavirus (CCoV) *

Elliott's Pet Care: Recommended

Yes

No

Canine Distemper (CDV) *

Elliott's Pet Care: Required

Yes

No

Canine Influenza Virus (CIV - H3N2) *

Elliott's Pet Care: Recommended

Yes

No

Canine Influenza Virus (CIV - H3N8) *

Elliott's Pet Care: Recommended

Yes

No

Canine Parainfluenza (CPIV) *

Elliott's Pet Care: Required

Yes

No

Canine Parvovirus *

Elliott's Pet Care: Required

Yes

No

Leptospirosis *

Elliott's Pet Care: Required

Yes

No

Rabies *

Santa Clara County: Required Elliott's Pet Care: Required

Yes

No

Rattlesnake *

Elliott's Pet Care: Recommended

Yes

No

Flea *

Elliott's Pet Care: Required

Yes

No

Heartworm *

Elliott's Pet Care: Required

Yes

No

Hookworm *

Elliott's Pet Care: Recommended

Yes

No

Roundworm *

Elliott's Pet Care: Recommended

Yes

No

Tick *

Elliott's Pet Care: Required

Yes

No

By providing information on this form, Client attests, represents and warrants that all information provided is complete and accurate. Client takes full responsibility for any damage or harm caused by Client omitting any information or providing any information that is misleading or inaccurate. *

Agree

Disagree

Electronic Signature *

First Name

Last Name

Today's Date *

MM

DD

YYYY