Client Intake Form PLEASE CONTACT US TO SCHEDULE BEFORE FILLING OUT THIS FORM "*" indicates required fields Owners Name* First Last Owners Phone*Owners Email Emergency Phone*Veterinarians Name* First Last Veterinarians Phone*Pet(s) information*NameBreedColors/Markings Add RemovePlease add a row for each pet. In the last 6 months has your pet had a Vet visit beyond wellness visits and vaccines? If yes, please explain:Vaccine Information*Vaccine NameExpiration DateTag # (if applicable) Add RemovePlease add a new row for each vaccine your pet has been given. Examples: Rabies, Bordatella, DPP. You MUST provide a copy or picture of pet's most recent vaccinations for our records to clients.tqk@gmail.com or text to 505-980-4480. Your pet cannot be boarded without current immunizations; DHLPP, Rabies, and Bordetella. Pets exempt from immunization must have a written statement from your veterinarian. Please be advised that while we require up-to-date vaccinations, your pet may still catch "kennel cough" even if it has been vaccinated! Please remember to provide proof of vaccinations before or at time of check in. Diet Information* I will supply my pet’s food. My pet will eat Kennel supplied food Feeding Instructions for your pet(s)*Please tell how much your pet(s) eats each day, and how often to feed. Eample: AM _____ Cup(s) PM ______ Cup(s) Can your dog have treats while boarding with us?* Yes No If your dog runs out of their own food, can they eat Kennel Supplied food?* Yes No If your pet decides to be a finicky eater, is it OK to add either canned food, cheese, or broth as an enticement?* Yes No If your pet develops diarrhea while boarding, may we administer Pepto or Pumpkin?* Yes No Is your dog an escape artist? If yes, please explain:Any fears? (I.E. Fireworks) If yes, please explain:Any anxiety? If yes, please explain:Any Aggressive History/Biting ? If yes, please explain:If your dog gets playtime, what do they like to do?Medication InformationMedication NameDoseSchedule Add RemoveMy pet will require Triple Quest Kennels to administer the following medications. Oral or topical medications only. Please add a row for each medicine needed.Can peanut butter or cheese be used to help administer medications ?* Yes No Any other health/medical instructions?Is there anything else we should know, or you would like to tell us about your pet?Consent* I agree to the TQK policies listed below.Injury and Illness Owner guarantees that the pet is in good health (unless otherwise disclosed below) and is fully vaccinated before their stay. Disclosure of medical conditions, illness, and/or behavioral issues: Owner recognizes there are inherent risks of injury or illness in any environment associated with numerous dogs while in daycare, boarding and grooming environments. Such risks include but are not limited to: • Exposure to parasites, viruses, and other infectious diseases passed from pet to pet or person to pet; • Lacerations, sprains, strains, broken bones, paralysis, orthopedic injuries. • Illness including diarrhea and vomiting, fatigue, dehydration, heatstroke, and even death. Knowing these inherent risks and dangers, it is understood by the owner that Triple Quest Kennels, LLC will not be liable for any injury or illness to pet while the pet is in their care. Triple Quest Kennels, LLC/Sonya Burr will exercise due diligence and reasonable care while caring for my pet and will not be liable for any problems that may arise. If a dog becomes otherwise ill or injured and is in need of immediate care, Triple Quest Kennels will transport the pet to the nearest open and able Veterinary Hospital and attempt to reach the owner while the pet is in transit. Owner understands he/she will be responsible for all charges related to the medical evaluation and/or treatment given by the Veterinary Hospital. Belongings Loss or Damage Owner understands that any personal items/belongings brought for use during boarding or daycare are liable to get destroyed and are at the owner’s sole risk. Custom Kare Kennel, INC is not responsible for items that are lost, destroyed, or damaged. We strongly recommend items be labeled in some way. The undersigned on behalf of any and all participants authorized or permitted to attend any lessons or boarding, agrees to defend, indemnify and hold harmless your dog trainer, Triple Quest Kennels, LLC/Sonya Burr (RELEASED PARTIES/TRAINER) and agents from all liability and damages for any claim, loss, or injury which may occur or may be alleged to have occurred to any person, animals, or property arising from or related to the training, consultations or lessons. The trainer reserves the right to refuse training any dog that is obviously sick, abused, neglected, or overtly aggressive. Furthermore, the dog owners agree that non-compliance with the recommendations of TRAINER constitutes non-liability to the trainer. Trainer cannot guarantee any individual dog’s ability to learn and/or understand training cues or signals or to desensitize to feared or aggression triggers. The Client agrees that TRAINER, its owners, officers, employees and agents, hereafter referred to as the “RELEASED PARTIES,” will not be liable for any injury, death or property damage resulting from the training, counseling, or advice supplied to Client. Acknowledgement of Risk: Client is aware of the present and continuing inherent risks of injury, death, and property damage to Client, Dog, and persons and dogs of some third party that are involved, and those not involved, in the activity of training, including without limitation risks due to dog bite or infectious disease. Client acknowledges that Dog’s behavior now and in the future is solely Client’s responsibility. Client is voluntarily engaged in training as an activity with knowledge of the known risks and other risks that may result from Dog’s participation in training, including but not limited to injury, death, or property damage from disease, stray dogs, running away, other dogs in training, other animals, or injury, death, or property damage caused by Dog to other dogs, animals or persons. Assumption of Risk: If Dog causes property damage, or bites or injures any dog, animal or person, including but not limited to the RELEASED PARTIES, during or after the term of this Agreement, Client agrees to assume full responsibility and liability for any injury, death or property damage, and Client agrees to pay all resulting losses and damages suffered or incurred, and to defend, indemnify, and hold harmless the RELEASED PARTIES from any and all resulting claims, demands, lawsuits, losses, costs of expenses, including attorney’s fees. Release of Liability: Client releases RELEASED PARTIES from all liability to the Client, and Client’s representatives, guardians, successors, assignees, heirs, children, and next of kin for all liability, claims, damage, or demands for personal injury, death, or property damage, to the Client or to the Client’s dog or dogs, arising from or related to this Agreement or to participation in training or boarding, whether the injury, death, or property damage occurs on or off the training site. Knowing and Voluntary Execution: Client acknowledges that he or she has carefully read this Agreement, understands its contents, and understands that this Agreement includes an assumption of the risk of Client’s Dog, and a release of the RELEASED PARTIES liability. The undersigned acknowledges that the RELEASED PARTIES are materially relying on this Agreement in allowing the Client to participate in the activity of training. Client acknowledges that Trainer has not represented, promised, guaranteed, or warranted that Dog will never bite, that Dog will not be dangerous or vicious in the future, that Dog will not exhibit other behavioral problems, or that the results of the training will last for any particular amount of time. This Agreement may be amended only by a written instrument signed by both Client and Trainer. I authorize RELEASED PARTIES to use: Film photographs, digital photographs, video footage, audio recordings, and testimonials procured while training. I fully understand the terms and provisions of this waiver, assumption of risk, and agreement to hold harmless. The statements contained in the Assessment Form are true to the best of my knowledge. Date MM slash DD slash YYYY SignatureCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
