Client Name *

First

Last

Pet’s Name

Pet’s Age

Client Email *

Client Phone *

Species

Canine
Feline

Breed

Is your pet:

Neutered/Spayed
Intact

Pick Up Date

Pick Up Time

Drop off / Pick Up is available Monday through Friday (7am - 6pm), Saturday (9am - 12pm) or Sunday at 4pm.

Pick Up Authority

Emergency Contact & Phone # *

Would you like your pet to have a bath before going home?

Yes
No

Would you like you pet to have any additional grooming services?

Yes
No

What food will your pet be eating?

OPPC food
Owner food

Okay to have OPPC food if run out of Owner Supplied Food?

Yes
No

How many times a day and what time of day do you feed your pet? AM and PM?

Quantity of each feeding

Owner Food Type & Amount (if applicable):

Medical Conditions:

Is your pet currently taking any medications?

Yes
No

1. Medication Name

Quantity Owner Supplied (please specify in mls or pills)

Dosing Instructions:

Time Last Given:

2. Medication Name

Quantity Owner Supplied (please specify in mls or pills)

Dosing Instructions:

Time Last Given:

3. Medication Name

Quantity Owner Supplied (please specify in mls or pills)

Dosing Instructions:

Time Last Given:

Items brought with pet/Special instructions:

Extra Services: (please check all you would like your pet to receive and specify the amount of times below)

Edible Bone
Frosty Paw
TLC (10 min.)
Potty Break (5 min.)

How many times would you like your dog to receive an edible bone?

How many times would you like your dog to receive a frosty paw?

How many times would you like your dog to enjoy TLC?

How many times would you like your dog to have extra potty breaks?

Extra Services: (please check all you would like your pet to receive and specify the amount of times below)

Cat nip
Play time
Grooming Services

How many times would you like your cat to receive cat nip?

How many times would you like your cat to have play time?

How many times would you like your cat to receive grooming services?

In signing below, I have reviewed the above information and agree that it is true and correct, including services requested, medical condition and/or medication information, feeding information and items brought to verify that they are true and correct. I guarantee I have provided all the essential medical and nonmedical information required to guarantee my pet a safe, healthy and happy stay at Olentangy Premier Pet Care, and I do not hold Olentangy Premier Pet Care responsible for any information not provided. *

I have read and understand

Owner/Agent Signature *

Clear Signature

Today's Date *