New Client Registration Form | Applied Canine Concepts

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Applied Canine Concepts New Client Registration Form

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RELEASE FORM PLEASE READ!!! I hereby certify that my dog(s) Is/are in good health, have not been ill with any communicable diseases within the last 30 days. I also have read and understand and agree to the following: Injury and indemnification: If Pet Owners pet (s) accidentally dies, becomes ill, injured or lost Pet Owner waives and releases Applied Canine Concepts, it’s employees, interns and volunteers from any claim arising from such incident. If Pet Owners pet(s) bite or injures Trainer, any other human or animal, Pet Owner will be responsible for any resulting injury and shall hold harmless and indemnify Applied Canine Concepts from any claim or suit that may be brought as a result of such incident. In addition, Pet Owner shall hold harmless and indemnify Applied Canine Concepts and its employees, interns and volunteers against any and all costs, expenses, liabilities and claims arising out of or relating to any acts of Pet owner’s pet(s) except for negligence or intentional misconduct on the part of Applied Canine Concepts, it’s employees, interns and volunteers .By filling out this form, I agree to all of the above and I understand and agree that all deposits and our services including but not limited to Boarding, training, grooming etc are NON REFUNDABLE and I will not stop payment or request a charge back on my credit card. This is a legal binding agreement.

Applied Canine Concepts Client Registration Form

Owner Information

First Name *Required*

Last Name *Required*

Phone Number *Required*

Email *Required*

Address

City

State | Province

Zip Code | Postal Code

Family Vet Clinic

How did you find us?

Emergency Contact (Include Phone Number)/Others Allowed to Pick Up

Owner Question #1: Has your dog ever shown aggression? Is your dog destructive?

Owner Question #2: Does your dog have a bite history? People / Dogs

Owner Question #3: Please enter CC information in case of emergency vet care

Pet #1 Information

Pet Name *Required*

Breed (Best Guess) *Required*

Sex *Required*

Color Description

Date of Birth

Applied Canine Concepts requires proof of vaccination.

Rabies Expiration

DPP Expiration

Bordetella Expiration

Vaccine #4 Expiration

Vaccine #5 Expiration

Microchip Code

Weight

Insurance Info

Feeding Notes

Medication Notes

Temperament Notes (Aggression, anxiety, etc? If extensive, tell us in person).

Additional Notes (Anything else we should know? If extensive, tell us in person.)

Pet Question #1: Does your dog have any allergies?

Pet Question #2: Is your dog a flight risk/ escape artist? Is your dog self destructive?

Pet Question #3: Is your dog on any medications?

Pet Question #4: Has your dog had diarrhea or vomited recently?

Pet Question #5: By Submitting this form I understand that any payment is NON REFUNDABLE

Pet Photo (Not Required. 5MB Max. Image Files Only) Click to Upload Pet Picture

Proof of Vaccinations (5MB Max. Only Images, No PDFs. Take a Picture of Document with Your Phone and Upload It.) Click to Upload a Picture of Proof of Vaccinations

Click Here to Add a Second Pet

Pet #2 Information

Pet Name *Required*

Breed (Best Guess) *Required*

Sex *Required*

Color Description

Date of Birth

Applied Canine Concepts requires proof of vaccination.

Rabies Expiration

DPP Expiration

Bordetella Expiration

Vaccine #4 Expiration

Vaccine #5 Expiration

Microchip Code

Weight

Insurance Info

Feeding Notes

Medication Notes

Temperament Notes (Aggression, anxiety, etc? If extensive, tell us in person).

Additional Notes (Anything else we should know? If extensive, tell us in person.)

Pet Question #1: Does your dog have any allergies?

Pet Question #2: Is your dog a flight risk/ escape artist? Is your dog self destructive?

Pet Question #3: Is your dog on any medications?

Pet Question #4: Has your dog had diarrhea or vomited recently?

Pet Question #5: By Submitting this form I understand that any payment is NON REFUNDABLE

Pet Photo (Not Required. 5MB Max. Image Files Only) Click to Upload Pet Picture

Proof of Vaccinations (5MB Max. Only Images, No PDFs. Take a Picture of Document with Your Phone and Upload It.) Click to Upload a Picture of Proof of Vaccinations

Click Here to Add a Third Pet

ALERT: If you have more than three pets, submit this form once with your first three pets. After submitting the first time, click the link to come back to the form (shown after you submit the form) and fill out this form again with the information for your other pets. The second time you fill it out, you only need to include your name, phone and email in the OWNER section because the business will already have the other info (address, emergency contact, etc) from the first time you submitted the form.

Pet #3 Information

Pet Name *Required*

Breed (Best Guess) *Required*

Sex *Required*

Color Description

Date of Birth

Applied Canine Concepts requires proof of vaccination.

Rabies Expiration

DPP Expiration

Bordetella Expiration

Vaccine #4 Expiration

Vaccine #5 Expiration

Microchip Code

Weight

Insurance Info

Feeding Notes

Medication Notes

Temperament Notes (Aggression, anxiety, etc? If extensive, tell us in person).

Additional Notes (Anything else we should know? If extensive, tell us in person.)

Pet Question #1: Does your dog have any allergies?

Pet Question #2: Is your dog a flight risk/ escape artist? Is your dog self destructive?

Pet Question #3: Is your dog on any medications?

Pet Question #4: Has your dog had diarrhea or vomited recently?

Pet Question #5: By Submitting this form I understand that any payment is NON REFUNDABLE

Pet Photo (Not Required. 5MB Max. Image Files Only) Click to Upload Pet Picture

Proof of Vaccinations (5MB Max. Only Images, No PDFs. Take a Picture of Document with Your Phone and Upload It.) Click to Upload a Picture of Proof of Vaccinations

Appointments & Bookings: If you want to request an appointment or booking with this business, click here to add those details.

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If the form does not submit, please scroll up and make sure all required pet and owner fields are filled in. If the issue persists, send an email to info@appliedcanineconcepts.com