Enrollment Form

Enrollment Form for Boarding, Day Stay, Daycare, Grooming

Complete our online form:  ENROLL NOW!

OR Just print and fill out this form.  You can bring it with you when you visit us for a tour OR email

it back to us at: admin@ThePurpleDogDefiance.com

Enrollment Form

Dog’s Name: __________________________________

Client’s Information

Name:____________________________________  Date:__________________________

Address:________________________________________________________________

Home Phone: ______________________________ Work Phone:___________________

Cell Phone: ____________________________      Can you receive text messages?  Y / N

Email:__________________________________________________________________

Emergency contact if you cannot be reached: ___________________________________

Phone: ________________________

How did you hear about us? ________________________________________________

If referred by a current client, we would like to thank them!

Pet Medical & Veterinary Information

Veterinary / Clinic Name: ____________________ Phone: _______________________

Veterinarian Name: ________________________   Fax: _________________________

Veterinarian Address: _____________________________________________________

List medical issues current or past you are aware of: _____________________________

________________________________________________________________________

Is your dog currently on any medication?  Y / N

Name of medication and purpose: ____________________________________________

________________________________________________________________________

Known allergies: _________________________________________________________

Does your dog have any medical restrictions on his/her activities?  Y/N

Explain: _______________________________________________________________

Neutered/Spayed?  Y/ N         Date: ______________

Dogs 6 months of age+ must be neutered/spayed

Bordetella Due Date: __________________ Distemper Due Date: _________________

Rabies Due Date: _____________________ Flea/Tick Product: ____________________

Influenza Due Date:  H3N2 ______________           H3N8______________

H3N2 and H3N8 is suggested but not required at this time.

All daycare participants and overnight stays are required to be current on all vaccines.  Please provide proof of vaccinations.  Your vet can e-mail us your records at admin@thepurpledogdefiance.com

 

Dog’s General Information

Dog’s Name: _____________________Birthday: _______________Age: _________

Sex:  M / F      Breed (or best guess): __________________________________________

Color: __________________________________________

Weight (approx.): _________ Is he/she microchipped? Y / N     Is chip data current Y / N

How long have you had him/her? ____________________________________________

Where did you get him/her? ________________________________________________

Is your dog housebroken or crate trained? ______________________________________

Has your dog ever escaped/attempted to escape by digging, jumping or climbing fences? Y / N                Explain:  ___________________________________________________

How does your dog generally react to other dogs? _______________________________

________________________________________________________________________

Has your dog ever bitten a person?  Y / N

If yes, explain: ___________________________________________________________

Does your dog dislike or fear any type of person?  Y / N

If yes, explain: ___________________________________________________________

Does he/she have any fears?  Y / N

If yes, explain: ___________________________________________________________

Does your dog jump on people?  Sometimes / Always / Never

Explain:  ________________________________________________________________

Any areas on his/her body that he/she doesn’t like to be touched?  Y / N

If yes, explain: ___________________________________________________________

Is your dog allowed to have treats?  Y / N

Behavioral Advisories (circle all that apply):  Play Biter      Digger             Fence Climber             Jumper             Excessive Barking      Excessive Marking      Excessive Mounting

Is there anything else we should know about your dog?

________________________________________________________________________

May we use your pet’s photo on our website or Facebook page?  Y / N

Daycare Enrollment form

Has your dog ever attended group play?  Y / N

If yes, how did your dog react to other dogs? ___________________________________

Are there other dogs in the household?  Y / N           How many? ___________________

Describe how they get along:  _______________________________________________

Has your dog ever been in a fight or bitten another dog?  Y / N

If yes, explain: ___________________________________________________________

Is your dog fond of a particular type (breed, size, temperament, etc.) of dog?  Y / N

If yes, explain: ___________________________________________________________

Does your dog automatically dislike any type of dog (breed, size, temperament etc.)?

Y / N               If yes, explain: _______________________________________________

Is your dog possessive of toys or food?  Y / N   Describe: _________________________

________________________________________________________________________

Has he/she shared toys or food with other dogs?  Y/ N         Describe:  _______________

________________________________________________________________________

Were there any problems?  Y / N       Describe:  _________________________________

________________________________________________________________________

How does your dog generally react to other dogs? _______________________________

________________________________________________________________________

RELEASE / HOLD HARMLESS AGREEMENT
The Purple Dog Defiance, LLC its owners, employee(s), representative(s) or any other person(s) affiliated with the company shall hereinafter be referred to as “The Purple Dog.”
By signing this form, you or your representative(s) ____________________________(print YOUR name) shall hereinafter be referred to as “CLIENT,” and agree not to hold The Purple Dog liable or sue for any injuries and/or death to my dog(s) while in the care of The Purple Dog.
Although, The Purple Dog screens the dogs for temperament, watches the dogs carefully, and does not take aggressive dogs, daycare can be hazardous due to dogs playing together. They can get rambunctious at times and we cannot be held responsible for injuries and/or death that may occur in and out of the daycare including the transporting of dogs.
If in my absence, my dog(s) should become ill or injured, or in need of veterinary care, The Purple Dog has my permission to consult with my veterinarian and I realize that The Purple Dog will make a reasonable effort to bring my dog(s) to its stated veterinarian. If my dog should require immediate or emergency care, I hereby give The Purple Dog permission to bring my dog to The Purple Dog associate veterinarians’ facility including Defiance Veterinary Clinic. I understand that I am responsible for all veterinary costs, including the transportation of my dog to and from the veterinarian.
I hereby declare that my dog has never shown aggression, bitten, injured or killed another dog or person. If my dog does harm another pet, I agree to pay all bills associated with the incident.
I hereby declare that my dog has not been exposed to any communicable diseases within the last 30 days, is on a flea/tick treatment plan and is fully vaccinated in accordance with The Purple Dog policy.
I understand that The Purple Dog cannot be held responsible for lost, dirty, damaged, or destroyed belongings left in The Purple Dog’s care.
By signing this form, you acknowledge that you understand and accept the terms and conditions set forth by this agreement.

OWNER SIGNATURE: ____________________________ DATE: ___________________

Print Name _________________________________________

VACCINATION RECORDS:

PLEASE EMAIL THE VACCINATION RECORDS REQUESTED BELOW AS SOON AS POSSIBLE TO: admin@ThePurpleDogDefiance.com
PET PARENT INFORMATION:

Name: ____________________________________________
Address: __________________________________________
City: __________________ State: ____ ZIP ____________Phone: ________________

PET INFORMATION:

Name: _____________________ Breed: _________________________ Weight: _____
Name: _____________________ Breed: _________________________ Weight: _____
Name: _____________________ Breed: _________________________ Weight: _____
Please Include copies of Vaccination Records for:

___Bordetella ___Distemper ___Rabies Influenza ___H3N2 ___H3N8

I hereby certify that I am the owner (Pet Parent) or authorized agent of the Pet Parent of the above described pet(s). Further, I hereby request and authorize this veterinarian to release the requested medical information for my pet(s) to The Purple Dog Defiance, LLC. I release the veterinarian and staff from any legal responsibility or liability for the release of information to the extent indicated as authorized herein. This authorization expires in 90 days from the date of signature. I understand I may revoke this authorization, but the revocation may not be applied retroactively once the information specified herein has been released.

PET PARENT SIGNATURE: _________________________________ DATE: _______________