Epic Blue Acres New Client Form

Last Name: ____________________________________________________

First Name: _________________________  Spouse: ___________________

Address: ______________________________________________________

City: ______________________________________  Zip: _______________

Home:                                         Cell:                                             Work:                   

Emergency Phone #s : ___________________________________________

E-Mail : _______________________________________________________

Driver’s License # : __________________(for check cashing purposes)

Names of people authorized to drop off/pick up your pet:_________________________

*Authorized people must show  picture I.D or we will not release your pet to them*

How did you hear about us?____________________ Referral name:_______________

  (If a friend referred you, please list their name. We give 10% off their pets next stay)

PET’S INFORMATION

Name: ______________________________ Sex: _________   Altered?   Y    N

Date of Birth (age) : ___________  Breed: _____________________________

Colors: _____________________________________  Weight :_____________

Medical Problems: _________________________________________________

Name: _______________________________ Sex: ________   Altered?   Y    N

Date of Birth (age) : ____________  Breed: ____________________________

Colors: ___________________________________  Weight :_______________

Medical Problems: _________________________________________________

Please include a copy of your pet(s)  Distemper, Rabies and Bordatella vaccinations

(must have been done 10-14 days prior to boarding)  and fecal results