Primary Owner *

Secondary Owner

Vehicle Gate Access Code

Designated Parking Spot Number/Location

Pedestrian Gate Access Code

Garage Access Code

Door Access Code

Lock Box Access Code

Alarm System Access Code

Keys Issued

Wi-Fi Network Information

Emergency Contact *

Primary Authorized Release

Secondary Authorized Release

Tertiary Authorized Release

Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Gender *

Male

Female

Unknown

Altered *

Yes

No

Unknown

Microchipped *

Yes

No

Unknown

County Registered *

Yes

No

Unknown

Grooming Services *

Professional

Nonprofessional

None

Training Services *

Professional

Nonprofessional

None

Are they fully house-trained? *

Yes

No

Depends/Unknown

Have they been properly crate-trained? *

Yes

No

Depends/Unknown

How many hours can they typically go between potty breaks? *

< 1

1 - 2

2 - 4

4 - 8

> 8

How many hours can they typically be left alone? *

< 1

1 - 2

2 - 4

4 - 8

> 8

Are they generally friendly and well-socialized with people? *

Yes

No

Depends/Unknown

Are they generally friendly and well-socialized with other dogs? *

Yes

No

Depends/Unknown

Are they generally friendly and well-socialized with cats? *

Yes

No

Depends/Unknown

Are they generally friendly and well-behaved around other types of animals, excluding dogs and cats *

Yes

No

Depends/Unknown

Are they permitted to visit and interact with other dogs at public dog parks? *

Yes

No

Depends

Are they permitted to go outdoors and participate in regular walks? *

Yes

No

Depends

Behavioral Concerns *

Select all applicable options

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 ever been involved in any bite incidents or shown aggressive behavior toward people or other animals? *

Yes

No

Could you please specify the parties involved in each incident, including whether it was a person, another animal, or both? *

Check all that apply.

Singular Person

Multiple Persons

Singular Canine

Multiple Canines

Singular Non-Canine Animal

Multiple Non-Canine Animal

Other

N/A

Were any of these incidents formally reported to local authorities in the county or counties where they occurred? *

Yes

No

N/A

Are the feeding times time-sensitive or required to be administered at specific intervals? *

Yes

No

Are there any known medical conditions or health concerns? *

Yes

No

Do they take any medication, including prescription, non-prescription, or supplements? *

Yes

No

Depends

Do they have any known allergies? *

Yes

No

General Veterinarian Clinic *

Emergency Veterinarian Clinic

Is your pet enrolled in a pet insurance policy? *

Yes

No

Bordetella Bronchiseptica (Kennel Cough) *

Elliott's Pet Care: Required

Yes

No

Borrelia Burgdorferi (Lyme Disease) *

Elliott's Pet Care: Recommended

Yes

No

Canine Adenovirus (CAV-1) *

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: Recommended

Yes

No

Canine Parvovirus (CPV-2) *

Elliott's Pet Care: Required

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

Leptospirosis *

Elliott's Pet Care: Required

Yes

No

Louse *

Elliott's Pet Care: Recommended

Yes

No

Mites *

Elliott's Pet Care: Recommended

Yes

No

Rabies *

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

Yes

No

Rattlesnake *

Elliott's Pet Care: Recommended

Yes

No

Roundworm *

Elliott's Pet Care: Recommended

Yes

No

Tapeworm *

Elliott's Pet Care: Recommended

Yes

No

Tick *

Elliott's Pet Care: Required

Yes

No

Whipworm *

Elliott's Pet Care: Recommended

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