| Jodie Keener JBK LLC Dog Intake Sheet 2/10/2008 Date________________________ BREED:___________________________________________________________________ SEX ______________________________________________________________________ DOB:_____________________________________________________________________ REGISTERED NAME: AKC REG#:_______________________________________________ CALL NAME: MICROCHIP NUMBER:_____________________________________________ OWNER(S) NAME:___________________________________________________________ (Responsible for Payment)____________________________________________________ E-MAIL: WORK PHONE:______________________________________________________ HOME PHONE: CELL PHONE:__________________________________________________ ADDRESS(ES):_____________________________________________________________ EMERGENCY CONTACT:_____________________________________________________ HOME PHONE: CELL PHONE:__________________________________________________ FOOD, BRAND: DAILY AMOUNT:_______________________________________________ Dogs are fed twice a day unless otherwise specified. SUPPLEMENTS & VITAMINS:__________________________________________________ MEDICATIONS:_____________________________________________________________ We always have standard medications on hand in case of emergencies. (benedryl, gas-x, pepto, etc) *All special foods, supplements/ vitamins and medications are to be provided and paid for by the Client unless other arrangements have been made. ALLERGIES:_______________________________________________________________ FAVORITE BAIT:____________________________________________________________ We normally have several types of bait, including beef liver, beef heart and chicken breasts. FAVORITE TREATS & TOYS:__________________________________________________ We normally give our dogs, smoked bones and biscuits. Due to medical disasters that can be caused by rawhide chews we choose not to provide these for dogs. RING TRAINING, EXPERIENCE & HABITS:_________________________________________ _________________________________________________________________________ GROOMING TABLE HABITS & EXPERIENCE:______________________________________ X-PEN HABITS:_____________________________________________________________ The x-pens are not for “exercising dogs.” We use the x-pens for the dogs to rest, relax and play. At the shows, each dog is exercised. VOIDING HABITS:_________________________________________________________ OBEDIENCE COMMANDS:__________________________________________________ _______________________________________________________________________ HABITS (Good & Bad):_____________________________________________________ KNOWN FEARS:__________________________________________________________ EXISTING MEDICAL CONDITIONS, INJURIES OR ISSUES:__________________________ _______________________________________________________________________ To the best of my knowledge, said dog has not had any communicable diseases in the last 30 days. ANY OTHER INFORMATION THAT WE SHOULD KNOW TO KEEP YOUR DOG HAPPY AND SAFE:__________________________________________________________________ _______________________________________________________________________ ATTENDING VETERINARIAN:________________________________________________ ADDRESS:______________________________________________________________ PHONE:_________________________________________________________________ LAST VACCINATIONS ADMINISTERED:________________________________________ DHLP-P/C RABIES BORDETELLA_____________________________________________ FLEA TREATMENT: HEARTWORM PREVENTATIVE:______________________________ CREDIT CARD INFORMATION (to be used for emergency veterinary treatment) ________________________________________________________________________ NAME AS IT APPEARS ON THE CARD:_________________________________________ BILLING ADDRESS FOR CARD:_______________________________________________ NUMBER: EXP: V-CODE ON BACK:_____________________________________________ I authorize that any and all veterinary charges may be applied to the above credit card. I authorize Jodie Keener and/ or any of her assistants to seek medical treatment for my dog. Client Signature: Date:_______________________________________________________ Agent Signature: Date:_______________________________________________________ AGENT & ASSISTANT NOTES_________________________________________________ _________________________________________________________________________ _________________________________________________________________________ WEIGHT:__________________________________________________________________ COAT CONDITION:__________________________________________________________ MARKS, BLEMISHES, DISCOLORATION:_________________________________________ TEETH:___________________________________________________________________ NAILS:____________________________________________________________________ EARS_____________________________________________________________________ CRATE BEHAVIOR:__________________________________________________________ Misc Notes: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ |
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