Doggy Daycare Application And Release Form

Owner Information

• Today's Date*
• Owner Name*

  Please enter your name.
• Co-owner

  (equal ownership, neither owner can be removed from the account without their authorization)

• Street Address*

  Please enter your address.
• City*

  Please enter your city.
• State* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaInternationalIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington, DCWest VirginiaWisconsinWyoming

  Please make a selection.
• Zip*

  Please enter your Zip.
• Primary Phone*

  Please enter your phone number.

  This isn't a valid phone number.
• Phone Type Home Cell Work
• Cell Phone Number to Receive Texts

  This isn't a valid phone number.
• Alternate Phone

  This isn't a valid phone number.
• Alternate Phone Type Home Cell Work
• Primary Email*

  Please enter your email address.

  This isn't a valid email address.

  (Please note, only one email can be listed per account. If there is another email currently listed on the account that is different from this one it will be removed and replaced with what you put here).

• How did you hear about us? *

  Please enter your how you heard about us.

  (Friend/Family member, Internet search, Social Media, Veterinary Referral, Drive-By, etc. If a friend or family member referred you, please list their name so we can thank them!) )

Pet Information

• Pet Name*

  Please enter your pet's name.
• Breed*

  Please enter breed.
• Age/Birthday*

  Please enter age/birthday
• Color/Markings

• Gender- Dog MUST be spayed/neutered if over 7 months of age*

  • Spayed Female
  • Neutered Male
  • Unaltered Male Under 7 Months
  • Unaltered Female Under 7

  Please make a selection.
• Approximate Weight

Veterinarian Information

• Primary Veterinary Practice(if different than NAH)
• Vet Phone

  This isn't a valid phone number.

General Information

• Where did you get your dog?
• How long have you had him/her?

• Has your dog ever attended a daycare or dog park before?

  • Yes
  • No

• If yes, was it a positive experience?

  • Yes
  • No
• If it was a negative experience for you or your dog, please explain why

• If your dog is over 40lbs, has he/she ever played with small dogs (less than 15lbs)?

  • Yes
  • No

• If your dog is less than 15 lbs, has he/she ever played with larger dogs (over 40lbs)?

  • Yes
  • No

Medical History

• Has your dog been in good health for the last 30 days?

  • Yes
  • No
• If no, please describe

• Is your dog allergic to any food or medication that you know of?

  • Yes
  • No
• If yes, please describe

• Is your dog currently taking any medications?

  • Yes
  • No
• If yes, please list medications and dosages

• Does your dog need medication while at daycare?

  • Yes
  • No
• If yes, list specific instructions

• Has your dog had any lameness issues in the past?

  • Yes
  • No
• If yes, please describe

• Does your dog have any other pre-existing medical conditions to note?

  • Yes
  • No
• If yes, please describe

Behavior Information

• Describe your dog's activity level

  • High
  • Medium
  • Low

• Select all situations where your dog may become unfriendly or frightened

  • Grabbing collar
  • Hugging
  • Removing from furniture
  • Touching while sleeping
  • Touching ears, mouth, paw, tail
  • Around other dogs
  • None
  • Other

• Describe your dog's unfriendly/frightened behavior (select all that apply)

  • Will bite
  • May bite
  • Growls
  • Snaps
  • Shows teeth
  • Freezes
  • Trembles
  • Moves away

• Is there anywhere on your dog's body that he/she does not like to be touched?

  • Yes
  • No
• If yes, please describe

• Has your dog ever growled at or bitten a person or another dog?

  • Yes
  • No
• If yes, please describe

• Has your dog ever been bitten by another dog?

  • Yes
  • No
• If yes, please describe

• Does your dog seem frightened or uneasy around any type of person (ie: men, women, children, strangers)?

  • Yes
  • No
• If yes, please describe

• Does your dog like to play with

  • Male dogs
  • Female dogs
  • Both male and female dogs

• Will your dog easily share toys with other dogs/people?

  • Yes
  • No
• If no, please describe

• Has your dog ever jumped a fence or barrier?

  • Yes
  • No
• If yes, how high was fence?

• Would you consider your dog an “Escape Artist?

  • Yes
  • No

• Is there any type or breed of dog that your dog dislikes?

  • Yes
  • No
• If yes, please describe
• What commands does your dog know?

  (It is very helpful if your dog has a good recall to their name and a strong "leave it" command.)

• Are there any other behavioral issues you wish to inform us about?

  • Yes
  • No
• If yes, please describe

The following individuals have permission to pick my dog up from daycare

• Name
• Phone

  This isn't a valid phone number.
• Name
• Phone

  This isn't a valid phone number.

Daycare Agreement and Liability Release

Please read each of the following statements and check ALL boxes to indicate that you have read and agree with each statement of release and liability*

• • I certify that my dog is in good health and has not been ill within the last 30 days. I also certify that I will not bring my dog to daycare if he/she is exhibiting symptoms of illness, particularly diarrhea/loose stools. I understand that if my dog exhibits symptoms of illness while attending daycare that he/she will be removed immediately and will not be allowed to return to daycare until symptoms have ceased for a period of at least 24 hours. This precaution will be taken to protect pets from contracting communicable diseases or parasites and to decrease the risk of spreading illness.

  Please make agree to terms
• • I agree that my dog has not shown aggression or threatening behavior towards any person or dog.

  Please make agree to terms
• • I understand the vaccination/exam requirements (Negative Giardia test prior to attending daycare for the first time, DHPP, Bordetella, Rabies, and annual intestinal parasite exam) for my dog to participate in day care. I also understand that if my dog is not current on these requirements, Needham Animal Hospital will update them at my cost during my dogs stay.

  Please make agree to terms
• • I understand that my dog must be flea and parasite free to participate. If fleas are noted on any animal, that animal will be treated immediately with an appropriate product. There will be an additional charge for any necessary flea or parasite treatment.

  Please make agree to terms
• • I understand that if my dog destroys Needham Animal Hospital property , particularly by damaging the artificial turf, that this will be grounds for dismissal from daycare.

  Please make agree to terms
• • I understand that daycare reservations are made by appointment so that NAH can ensure adequate staffing of the play yard per state licensure regulations. I understand that reservations cancelled later than 7:30am on the day of the reservation or no show reservations will lead to the deduction of one package day or a $30 fee for non package holders.

  Please make agree to terms
• • I understand the hours of Needham Animal Hospital. I understand that a $15 fee will be applied if I pick up my dog after closing. I understand that my dog will be boarded overnight if I will be more than 15 minutes late to pick up. Regular boarding rates will apply.

  Please make agree to terms
• • I understand that, while Needham Animal Hospital takes careful precaution to avoid injury or illness to my pet, these risks do exist and that I am financially responsible for the associated veterinary care if my dog is injured or becomes ill as a result of attending daycare. I understand that, much like allowing a child to attend daycare or play a contact sport, risks of illness or injury are inherent and the associated medical costs are the responsibility of the parent (pet owner). I understand and agree that Needham Animal Hospital and its staff are not liable for any accident or injury that may occur. Examples of potential illness or injury include but are not limited to: Bite wounds, lameness injuries, intestinal parasites, oral papillomas, kennel cough or other infectious diseases. I understand that I am encouraged to discuss any concerns I have with the Needham Animal Hospital staff before I sign this release. I agree to let my dog participate in canine corporate play.

  Please make agree to terms
• • I understand that any problem, including but not limited to injury or accident, illness, or death, that occurs while on the Needham Animal Hospital premises will be treated as deemed best by the veterinarian on duty. Should the hospital not be able to reach me or my emergency contact within a reasonable amount of time, I authorize the attending veterinarian to administer the minimum medical treatment required to ensure the health and safety of my pet. I will also assume full financial responsibility for any subsequent expenses incurred. If I prefer for my pet to be treated at another veterinary hospital (in the event of injury) I understand that it is my responsibility to transport my pet to that facility for treatment.

  Please make agree to terms
• • If I prefer for my pet to be treated at another veterinary hospital (in the event of injury) I understand that it is my responsibility to transport my pet to that facility for treatment.

  Please make agree to terms
• • I certify that I am the owner or authorized agent for the owner of the above named pet and I authorize Needham Animal Hospital to admit this pet to their daycare facility. I accept the financial responsibility for this pet and I understand that payment is due at the time services are rendered.

  Please make agree to terms
• • I authorize Needham Animal Hospital to take photographs /video of my dog while participating in corporate play and I authorize the use of these photos in hospital marketing material and on social media websites.

  Please make agree to terms
• Additional Comments
• Signature*

  Please enter your name.