Dog Daycare Evaluation

To be accepted into our day care program, each potential day care guest must:

1. Complete this Day Care Registration Form 24-48 hours PRIOR to your Daycare Reservation.
2. Meet our vaccination and temperament requirements.
3. Must be spayed/neutered if over 6 months of age.

Client Information

Are you a current client of Lowell Road Veterinary Center?(Required)

Owner Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Emergency Contact

Owner Name(Required)

First Last

Emergency Contact Phone(Required)

Relationship to Owner(Required)

Others authorized to pick up my pet(Required)

Pet Information

Pet's Name(Required)

Age of Pet(Required)

Breed(Required)

Approximate Weight(Required)

Sex(Required)

Male/Female(Required)

Female Spayed/Male Neutered(Required)

Current Veterinarian (if not Lowell Road Veterinary Center)(Required)

Clinic Name(Required)

Clinic Phone Number(Required)

General Information

How did you hear about Lowell Road Veterinary Center's Dog Daycare?(Required)

How long have you owned your dog?(Required)

Where did you get your dog?(Required)

Indicate the level of dog socialization that best describes your dog.(Required)

Has your dog had any problems previously in a dog daycare or other off-leash social environment?(Required)

Has your dog ever climbed a fence?(Required)

Health Information

Is your dog on a flea, tick and heartworm preventative?(Required)

Has your dog ever been diagnosed with any orthopedic injuries (i.e ACL tears, Cruciate ligament injury, arthritis, dysplasia)(Required)

Does your dog have any other physical disabilities?(Required)

Does your dog have any allergies? (i.e food or environmental)? If yes, please specify.(Required)

Is your pet taking any medications? If yes, please specify medication(s) and the condition being treated:(Required)

Behavior Information

Are there any particular types of people your dog seems to automatically fear or dislike?(Required)

If yes, please describe:

Has your pet ever bitten a person?(Required)

Is your dog frightened by anything? (i.e thunderstorms, fireworks, yelling)?(Required)

If yes, please describe:

Has your pet ever bitten another dog?(Required)

Has your dog had a problem in any of the following areas:(Required)

Mouthing

Food bowl aggression

Toy aggression

Barking

Digging

House training

Ignoring Commands

Other

Select all that apply.

Indicate the overall level of exercise that best describes your dog’s routine:(Required)

Terms & Conditions

PHOTO RELEASE(Required)

Yes

I grant Lowell Road Veterinary Center (LRVC), it's representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that LRVC may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and web content.

If your pet requires basic medical attention while in our care (example: hot spot, skin abrasions, upset stomach causing vomiting and/or diarrhea, etc.)- do you authorize treatment?(Required)

NOTE: If we do not hear back from you within 4 hours we will proceed as recommended by the Veterinarian on duty. We will always contact you as soon as possible for any urgent or emergency medical situations.

DAY CARE TERMS AND CONDITIONS(Required)

I agree to the day care terms and conditions.

To ensure the health and safety of your dog and all other guests, we require that all of our clients agree and comply with the following terms and conditions:

I specifically represent to Lowell Road Veterinary Center (LRVC) that I am the legal owner of my dog. In addition, my dog is healthy, meets LRVC's vaccination standards, has not harmed or shown aggression or threatening behavior towards any person(s) or other dog(s) and has not been exposed to any known communicable disease within the 30 days immediately prior to admission to day care.

I further represent that each time my dog is brought to LRVC, I will be recertifying that my dog is in good health and has not had any communicable illness of any kind for 30 days prior to admission. I further agree to inform LRVC of any changes in my dog’s condition and/or behavior prior to any day care visit.

I understand a Daycare Reservation is to be completed 24-48 hours before dropping off my pet for daycare. There is an additional fee that may be applied to the daycare charge if no reservation was received, if there is availability for your dog to stay.

Consent(Required)

I agree to the below financial policy

Payment is due at time of service. Forms of payment accepted include cash, all major credit cards, Care Credit, and Scratchpay. Checks are not accepted.

Consent(Required)

I agree to the below policy

I, the undersigned, certify that I am 18 years of age or older and I am the legal owner (or authorized agent of the owner) of the patient listed above. I agree to assume financial responsibility for all charges incurred and agree to pay such charges at the time of services rendered. I also understand that personal checks are not accepted. I am responsible for all interest and collection fees on any unpaid balance, as well as reasonable attorney fees and court costs associated with collection of unpaid balances. I acknowledge that the above information is true and accurate to the best of my knowledge.

Lowell Road Veterinary Center (LRVC) is an ABUSE-FREE WORKPLACE. By initialing here, I understand that LRVC has a ZERO TOLERANCE policy for profanity and verbal abuse. I further understand that any profane, abusive, or hostile behavior or language directed at any member of the LRVC team will result in immediate removal from the hospital, and I will no longer be allowed to bring any of my pets to LRVC in the future, for any reason.

Consent

I agree to the privacy policy.

By checking this box, you agree to the terms below:

I understand daycare drop off is between offered between 7:00-9:00AM and pick up is between 3:00-5:45PM. There is no availability to drop off or pick up between 9am-3pm. Dogs not picked up by closing time (5:45 P.M.) will be charged $10.00 for every 15 minutes after 5:45 P.M.

I understand that my dog is required to be fully vaccinated (including distemper, parvo, rabies and bordetella) and have a negative fecal test every 6 months, and I will provide BVMC with proof thereof from my veterinarian. I acknowledge that it is my responsibility to ensure that my dog continues to be fully vaccinated and that BVMC reserves the right to refuse daycare services if it is not fully vaccinated.

I understand that the leash-free environment at LRVC provides dogs the opportunity to play in close physical contact, including with their teeth and paws. I acknowledge that no amount of supervision or personalized care by LRVC, its agents or employees, can prevent the possibility of injury or illness to my dog.

I agree to indemnify and hold harmless LRVC from any and all claims, liabilities, costs and expenses, including court costs and attorney fees, arising out of any harm or injury caused by my dog to other dogs or persons. I authorize LRVC to do whatever is deemed necessary for the safety, health and well-being of my dog and I agree to assume full financial responsibility for any and all medical expenses incurred. I expressively waive and relinquish any and all claims against LRVC, its employees, agents, and representatives for any injury, illness, or harm to my dog. Under no circumstances will LRVC be liable for consequential damages or damages beyond the replacement value of my dog.

I understand LRVC reserves the right to refuse admittance to any dog that displays signs of untreated or potentially contagious conditions, demonstrates aggressive behavior, or who fails our standard health and temperament policies. I further understand and agree that any problems that develop with my dog will be treated as deemed appropriate by the staff of BVMC, in their sole discretion.

In the event any provision of this agreement is declared by a court of competent jurisdiction to be unenforceable, the remaining provisions shall remain in full force and effect. I certify that I have read, understand, and agree to be bound by the terms and conditions as set forth herein.
The clinic and staff will not be held liable for problems that develop provided reasonable care and precautions are followed.

I have confirmed that all my contact information listed above is accurate.

I understand that my pet is to be dropped off and picked up during the listed hours only or an additional fee may apply.

I acknowledge that I have read, and do hereby accept the terms and conditions contained in this agreement.

Authorization Signature(Required)

First Name Last Name

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Comments

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