Dog Info Form

Owner's First Name*

Owner's Last Name*

Address*

City*

State*

Zip Code*

Home Phone*

Work Phone*

Cell Phone*

Email Address*

Dog's Name

Dog's Gender

Male

Female

Has your dog been spayed or neutered?

Yes

Dog's Breed

Dog's Age

Dog's Veterinarian's Name

Veterinarian's Address

Veterinarian's Phone

All dogs must be up to date on all vaccinations.

Date and Type of Last Vaccinations

Any Physical problems we need to know?

Any known Allergies? (food, medication etc.)

Has your dog bitten anyone? Why?

How does your dog react around children?

How does your dog react around other dogs?

How does your dog react around other animals?

How does your dog react to loud noise? (thunder,fireworks, etc.)

Is there any other information we should know?

I understand that my dog’s stay at Gussie’s Place is not without the possible risk of illness or injury, even when the utmost care is taken. I agree not to hold Gussie’s Place – Gail and Jerry Stewart or any employee, responsible or liable for such injury or illness should that injury or illness occur even when all normal and reasonable precautions have been taken. At Gussie’s Place we always try to contact the owner in the event of an accident or injury, but in the event of a true emergency, we put the dog’s needs first and foremost. In the event that my dog needs medical assistance (including anesthesia), I agree not to hold Gussie’s Place – Gail and Jerry Stewart or any employee, animal hospital or any other veterinary or emergency clinic, responsible or liable for unexpected reactions to medications or anesthesia when all normal and reasonable precautions have been taken. I have read the above disclaimer and agree to it's terms.*

I have read the above disclaimer and agree to it's terms.*

Yes

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