Pre-Screening Application - Dutch Heritage Farms

IF YOU DO NOT HEAR FROM ME IN 24 HOURS PLEASE CALL THIS NUMBER: (503) 913-5052

PAMPERED PET LODGE PRE-SCREENING APPLICATION

Separate form for each pet

Check-in Date

Check-in Time

Transportation Required

Check-out Date

Check-out Time

Transportation Required

Pet Name:

Breed:

Gender:

Age:

Veterinarians Name:

Phone:

Canine Vaccinations

Current Bordetella Vaccination, Kennel Cough (within the past 6 months)

Current DHLPP Vaccination (Distemper, Hepatitis, Leptospirosis, Parvovirus, Parainfluenza)

Current Rabies Vaccination

Feline Vaccinations

Current FVRCP (Feline Viral Rhinotracheitis, Calicivirus, and Panleukopenia)

Current Rabies, Leukemia and Bordetella (within the past 6 Months)

We must receive your pet/pet’s vaccination records within 24 hours of the time of booking.

You must treat your pet/pets for fleas and ticks at least 5 days prior to arrival. At check in, if your pet is found to have fleas or ticks, we will treat your pet/pets based on the current market rate of the treatment methods and medicines we utilize.

Pets Weight:

Spayed/Neutered:

Last Heat:

Potty Trained

Does your Pet have any known food allergies, dietary restrictions, or aversions? If yes, please describe and be specific. (Chicken, Beef, Seafood, Other)

Are you providing your pets food, snacks and treats during their stay? If so, please bring enough excess to allow for increased hunger, spillage. Clearly mark all food bags, cans etc. with your pet’s name and provide detailed instructions of their current eating times and amounts.

Does your Pet have any special medical needs or existing wound care we should be aware of?

Any urinary or fecal incontinence?

Is your Pet on any Medication, Supplements or Injectables we will be administering? Please provide more than enough for your pets stay as well as detailed instructions on dispensing times and quantities.

Has your pet ever boarded before? Any separation anxiety, fears, shyness?

Has your pet ever bitten or shown aggression towards a person and or animal?

Any additional information about your pet?

Please upload your pets vaccination records here.

Max. file size: 100 MB.

Owner Information

PET OWNER/S NAME:

PHONE:

OCCUPATION:

RELATIONSHIP TO ADDITIONAL PET OWNER?

PET OWNER/S NAME:

PHONE:

OCCUPATION:

RELATIONSHIP TO ADDITIONAL PET OWNER?

Local Address:

Local Address: City: State: Zip:

Destination Address:

Destination Address: City: State: Zip:

REASON FOR TRAVEL:

EMAIL ADDRESS:

EMERGENCY CONTACT INFORMATION
(You authorize to pick up your pet in case of emergency)

NAME:

PHONE:

RELATIONSHIP TO OWNER/S

NAME:

PHONE:

RELATIONSHIP TO OWNER/S

To the best of my knowledge, all the information provided herein is accurate.
I understand that the rates are based on the individual needs of my pet based solely on the information provided herein.
I understand that if my daily rate needs to be adjusted, I will be contacted by Pampered Pet Lodge Staff.
I understand that a $75.00 deposit is required at booking and to be applied to my final billing.

Signature

PRINTED

DATE

Signature

PRINTED

DATE

Please fill, sign and scan or text to 503.913.5052 or [email protected]
Once reviewed, we will call you with your rate, have you sign the boarding contract and pay the $75.00 deposit.

This field is for validation purposes and should be left unchanged.

IF YOU DO NOT HEAR FROM ME IN 24 HOURS PLEASE CALL THIS NUMBER: (503) 913-5052

PAMPERED PET LODGE PRE-SCREENING APPLICATION

Owner Information

EMERGENCY CONTACT INFORMATION (You authorize to pick up your pet in case of emergency)

EMERGENCY CONTACT INFORMATION
(You authorize to pick up your pet in case of emergency)