Please download the attached form and bring with you when you drop off your dog
| stillwater_information_sheet.docx |
Date Form Completed :___/___/___
DOG NAME:
*****************************************************************************************************
Information in this below to be filled out by Stillwater Kennels LLC
__Shot Record Received
__Heartworm Medicine Due Date of Month (i.e. 19th)
__Flea/Tick/Dewormer Due Date of Month
*****************************************************************************************************
Owner’s Name:____________________________________________
Owner’s Address: __________________________________________
_________________________________________________________
_________________________________________________________
Home Phone:__________________ Cell Phone:__________________
____Yes, I can receive text messages
Email Address:_____________________________________________
Emergency Contact:_________________________________________
(Name)
_________________________________________________________
(Address)
_________________________________________________________
(Phone)
Health Information
Veterinarian:______________________________________________
________________________________________________________
(Address)
________________________________________________________
(Phone)
Page 2 ---------------------------------------------------------
Dogs Name:___________________________________________________
Shot’s Completed:
_____________________________________________________________
(Date)
Health Problems:_______________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Food
Type of Food:__________________________________________________
How Many Times a Day:__________________________________________
Medication, Allergies, Special Instructions
Please list all medications, allergies and special instructions in the following:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
We will give you permission to authorize emergency medical care for our pet(s) as
deemed necessary by a veterinarian, and understand that we will be responsible
for full payment and care of our pet(s).
_______ Yes _______ No
Owner Signature___________________________________Date______________
DOG NAME:
*****************************************************************************************************
Information in this below to be filled out by Stillwater Kennels LLC
__Shot Record Received
__Heartworm Medicine Due Date of Month (i.e. 19th)
__Flea/Tick/Dewormer Due Date of Month
*****************************************************************************************************
Owner’s Name:____________________________________________
Owner’s Address: __________________________________________
_________________________________________________________
_________________________________________________________
Home Phone:__________________ Cell Phone:__________________
____Yes, I can receive text messages
Email Address:_____________________________________________
Emergency Contact:_________________________________________
(Name)
_________________________________________________________
(Address)
_________________________________________________________
(Phone)
Health Information
Veterinarian:______________________________________________
________________________________________________________
(Address)
________________________________________________________
(Phone)
Page 2 ---------------------------------------------------------
Dogs Name:___________________________________________________
Shot’s Completed:
_____________________________________________________________
(Date)
Health Problems:_______________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Food
Type of Food:__________________________________________________
How Many Times a Day:__________________________________________
Medication, Allergies, Special Instructions
Please list all medications, allergies and special instructions in the following:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
We will give you permission to authorize emergency medical care for our pet(s) as
deemed necessary by a veterinarian, and understand that we will be responsible
for full payment and care of our pet(s).
_______ Yes _______ No
Owner Signature___________________________________Date______________