FieldsetHow did you hear about us? When is your birthday? I (Name of Client) At Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryHereby confirm that I am the legal owner of the below listed pet and that I authorize Cozy Care Pet Services to provide pet sitting services from To These dates can be changed verbally as needed. Pet Name Date of Birth or Pet Age Breed Primary Color: Secondary Color(s): Can we use your pet(s)’ photos on our marketing materials? Weight Gender Rabies Vac #: Expiration Date Health Conditions or Allergies? Diet Restrictions? If yes, please explain: Where did you acquire your pet? How long have you had your pet? Has your pet ever growled, snapped , hissed, clawed, or lunged at anyone or any other pets? YesNoIf yes, please explain: Has your pet ever bitten or hurt anyone? YesNoIf yes, please explain: Is your pet on medication or supplements? YesNoIf yes, please list medications and what they are for What brand and protein do you feed your pet? How much would you like us to feed your pet? Breakfast: Lunch Dinner: What are their eating habits like (consistent, grazes, normally eats half, etc.)? Bedtime Snack: Where is the food located? Where are other supplies located? Are there any other special instructions? What is the best way to reach you when you are away? If there were one item that you could change about your pet, what would it be? Would you like to list an additional contact in case we can’t reach you? If so, please list below: Name: Relationship: Phone Number: Email What Vet do you use? Name and Company Name: Vet’s Phone Number: Has your pet had surgery of any kind? If yes, please explain: Is there anything that your pet is afraid of? If yes, please explain: Does your pet react when you take toys from his mouth or take food away? Option 1Option 2Option 3If yes, please explain: What commands does your pet know and consistently obey? What keywords do they best respond to? Are they an escape artist? Option 1Option 2Option 3If so, please explain: Please share any other behavioral traits or issues regarding your pet: What heartworm medication is your pet on? What flea and tick medication is your pet on? Breed “By signing this electronically, I certify that my electronic signature is sufficient as my written signature and that the above information is true and accurate to the best of my knowledge.” Electronic Signature: I agreeI disagreeDate: Schedule a Meet and Greet? Option 1Option 2Option 3This visit will give all of us an opportunity to get acquainted, have an open discussion, and allow us to answer any questions you may have about Cozy Care. It will help us learn exactly what your pet’s normal daily routine consists of so that we may cus Pick Date VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
