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CUSTOMER INFORMATION
Your Information
Name _________________________
Address _________________________
_________________________
Phone _________________________
Emergency Contact (Home Emergency)
Please provide a contact other than yourself who should be contacted if you
cannot be reached in the event of an emergency involving your house
Name ____________________________
Phone ____________________________
PET INFORMATION
Pets
Name ___________________________
Breed ___________________________
Age ______ Sex ______ Birthday___________
Any special needs? (e.g., medical, allergies, separation anxiety, microchip)
__________________________________
__________________________________
__________________________________
Name ___________________________
Breed ___________________________
Age ______ Sex ______ Birthday___________
Any special needs? (e.g., medical, allergies, separation anxiety, microchip)
__________________________________
__________________________________
__________________________________
Please use additional sheets if necessary.
Vet Information
Name __________________________
Address __________________________
__________________________
Phone __________________________
Emergency Contact (Pet Emergency)
Please provide a contact other than yourself who should be contacted if you
cannot be reached in the event of an emergency involving the health and/or
safety of your pet(s)
Name ____________________________
Phone ____________________________
Emergency Authorizations
In the event that me pet requires emergency care and I am unreachable, I
authorize Loving Paws to spend up to $_____________ for treatment. I will
be responsible for all charges incurred, by pre-arrangement with the
veterinarian of an authorized credit card or invoice.
In the event of the death of my pet, I wish
______________________________________
______________________________________________________________
______________________________________________________________
____________________
In the event that something should happen to me, I wish my pets to go to
_____________________________________________
_____________________________________________
_____________________________________________
I certify that my pet is current on all vaccinations.
I will notify Loving Paws on arrival at home to avoid any additional charges.
By signing and dating below you are acknowledging that you have read and
understand the rates and services listed.
Signature ________________________
Date ______________
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