Name
*
First Name
Last Name
Email Address
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Your Primary Phone
*
(###)
###
####
Emergency Contact
*
Emergency Contact Phone
*
(###)
###
####
Pet Drop Off Date
MM
DD
YYYY
Pet Pick Up Date
MM
DD
YYYY
Pet's Name
*
Pet's Breed
Pet's Color
Pet's Age
Pet's Gender
*
Male
Female
Is your dog spayed or neutered?
*
Yes
No
What do you feed your dog?
How often do you feed your dog and how much?
Name of Veterinarian and Clinic
*
Veterinarian Phone
*
(###)
###
####
May we contact the Veterinarian?
*
Yes
No
Is your dog aggressive?
*
Yes
No
Has your dog ever bitten a person or another animal?
*
Yes
No
Does your dog guard his toys or bowl?
*
Yes
No
Is your dog reactive on a leash?
*
Yes
No
Is your dog a flight risk?
*
Yes
No
Does your pet have fleas, ticks or parasites?
*
Yes
No
What flea and tick prevention do you use? Last time given?
*
What heart worm prevention do you use? Last time given?
*
Is your animal okay with being touched or handled?
*
Yes
No
Any Diseases or Injuries?
*
Yes
No
If Yes, please describe
Are there any particular health conditions that your animal either previously had or is currently experiencing, such as allergies, respiratory, skin or degenerative conditions, joint/bone problems, digestive ailments, cancers, tumors, infections, and fevers? If so, please describe
List any medications or supplements
Was is the best thing about your dog?
Describe any unique behavior
Has your animal ever had massage, reiki, healing touch or hydrotherapy?
*
Yes
No
How would you like these healing modalities to help your animal?
Statement – I have stated herein all medical and behavioral issues affecting my animal that I am aware of and will update Camp Kibble of any changes in my animal's health or behavior. I understand that Camp Kibble and its practitioners must be aware of any and all existing physical/emotional conditions of my animal in order to provide the appropriate therapy. Please check the box to agree with the statement
*
Indemnity, Release and Liability Waiver – I, the person named on this form, warrant that I am the owner or person responsible for the animal(s) brought in for services at New Beginnings A Wellness Garden and Camp Kibble, and therefore accept and promise full responsibility by this Indemnity for damage to property, or injury, or death, to persons or other animals arising out of the use of the grounds and pool and the actions and conduct of me and my animal(s), and accordingly agree to indemnify New Beginnings A Wellness Garden and Camp Kibble and its owners, employees, independent contractors and independent therapists, for money, damages, and attorneys fees; and further waive all personal claims and release New Beginnings A Wellness Garden and Camp Kibble, its owners, employees, independent contractors and independent therapists for damage, injury or death sustained by me, arising out of my participation in the activities and services of New Beginnings A Wellness Garden and Camp Kibble, or presence on or use of the premises where services are performed; and further waive subrogation claims of insurers.
*