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Daycare Application and Release Form

Daycare Application and Release Form

Must be an established veterinary client to apply. Exceptions may be made for overnight boarding reservations

All dogs must attend a scheduled, no charge orientation day so that our staff can assess their behavior to determine if they are an appropriate candidate for group play. All dogs must have proof of vaccines before joining daycare. Vaccinations required: Distemper/Parvo, Bordetella, and Rabies. All dogs are required to have current a negative intestinal parasite exam and this test must be repeated annually. A negative giardia test is required prior to orientation day. All dogs over 7 months of age must be spayed or neutered to join in group play. Puppies are allowed to participate 2 weeks after completing their full vaccination series. All dogs must be flea and parasite free and must not be exhibiting any symptoms of illness such as coughing/sneezing, vomiting, or diarrhea. We have no breed or size restrictions. Dogs that exhibit aggressive, bullying, disruptive or destructive behaviors will not be permitted. At this time we do NOT have a separate yard for small dogs.

***Daycare is open Monday-Friday 7am- 6pm and Saturdays from 8am-5pm***

Owner Information

Please answer all questions and elaborate on any abnormal symptoms or behavior in the area provided.

Today's Date(Required)

MM slash DD slash YYYY

Owner Name(Required)

Co-owner Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Phone(Required)

Phone type

Cell Phone Number to Receive Texts

Alternate Phone

Alternate Phone type

Primary Email(Required)

(Please note, only one email can be listed per account. If there is another email currently listed on the account that is different from this one it will be removed and replaced with what you put here).

How did you hear about us?(Required)

(Friend/Family member, Internet search, Social Media, Veterinary Referral, Drive-By, etc. If a friend or family member referred you, please list their name so we can thank them!)

Pet Information

Pet's Name(Required)

Breed(Required)

Age/Birthday(Required)

Color/Markings(Required)

Gender- Dog MUST be spayed/neutered if over 7 months of age*(Required)

Spayed Female

Neutered Male

Unaltered Male Under 7 Months

Unaltered Female Under 7

Approximate Weight(Required)

Primary Veterinary Practice(Required)

(if different than NAH)

Vet Phone(Required)

General Information

Where did you get your dog?(Required)

How long have you had him/her?(Required)

Has your dog ever attended a daycare or dog park before?(Required)

Yes

If yes, was it a positive experience?

Yes

If it was a negative experience for you or your dog, please explain why

If your dog is over 40lbs, has he/she ever played with small dogs (less than 15lbs)?(Required)

Yes

If your dog is less than 15 lbs, has he/she ever played with larger dogs (over 40lbs)?(Required)

Yes

Medical History

Has your dog been in good health for the last 30 days?(Required)

Yes

If no, please describe

Is your dog allergic to any food or medication that you know of?(Required)

Yes

If yes, please describe

Is your dog currently taking any medications?(Required)

Yes

If yes, please list medications and dosages

Does your dog need medication while at daycare?(Required)

Yes

If yes, list specific instructions

Has your dog had any lameness issues in the past?(Required)

Yes

If yes, please describe

Does your dog have any other pre-existing medical conditions to note?(Required)

Yes

If yes, please describe

Behavior Information

Describe your dog's activity level(Required)

High

Medium

Low

Select all situations where your dog may become unfriendly or frightened(Required)

Grabbing collar

Hugging

Removing from furniture

Touching while sleeping

Touching ears, mouth, paw, tail

Around other dogs

None

Describe your dog's unfriendly/frightened behavior (select all that apply)(Required)

Will bite

May bite

Growls

Snaps

Shows teeth

Freezes

Trembles

Moves away

Is there anywhere on your dog's body that he/she does not like to be touched?(Required)

Yes

If yes, please describe

Has your dog ever growled at or bitten a person or another dog?(Required)

Yes

If yes, please describe

Has your dog ever been bitten by another dog?(Required)

Yes

If yes, please describe

Does your dog seem frightened or uneasy around any type of person (ie: men, women, children, strangers)?(Required)

Yes

If yes, please describe

Does your dog like to play with(Required)

Male dogs

Female dogs

Both male and female dogs

Will your dog easily share toys with other dogs/people?(Required)

Yes

If no, please describe

Has your dog ever jumped a fence or barrier?(Required)

Yes

If yes, how high was fence?

Would you consider your dog an “Escape Artist?(Required)

Yes

Is there any type or breed of dog that your dog dislikes?(Required)

Yes

If yes, please describe

What commands does your dog know?(Required)

(It is very helpful if your dog has a good recall to their name and a strong "leave it" command.)

Are there any other behavioral issues you wish to inform us about?(Required)

Yes

If yes, please describe

The following individuals have permission to pick my dog up from daycare

Name

Phone

Name

Phone

Daycare Agreement and Liability Release

Please read each of the following statements and check ALL boxes to indicate that you have read and agree with each statement of release and liability*

I certify that my dog is in good health and has not been ill within the last 30 days. I also certify that I will not bring my dog to daycare if he/she is exhibiting symptoms of illness, particularly diarrhea/loose stools. I understand that if my dog exhibits symptoms of illness while attending daycare that he/she will be removed immediately and will not be allowed to return to daycare until symptoms have ceased for a period of at least 24 hours. This precaution will be taken to protect pets from contracting communicable diseases or parasites and to decrease the risk of spreading illness.

I agree that my dog has not shown aggression or threatening behavior towards any person or dog.

I understand the vaccination/exam requirements (Negative Giardia test prior to attending daycare for the first time, DHPP, Bordetella, Rabies, and annual intestinal parasite exam) for my dog to participate in day care. I also understand that if my dog is not current on these requirements, Needham Animal Hospital will update them at my cost during my dogs stay.

I understand that my dog must be flea and parasite free to participate. If fleas are noted on any animal, that animal will be treated immediately with an appropriate product. There will be an additional charge for any necessary flea or parasite treatment.

I understand that if my dog destroys Needham Animal Hospital property , particularly by damaging the artificial turf, that this will be grounds for dismissal from daycare.

I understand that daycare reservations are made by appointment so that NAH can ensure adequate staffing of the play yard per state licensure regulations. I understand that reservations cancelled later than 7:30am on the day of the reservation or no show reservations will lead to the deduction of one package day or a $30 fee for non package holders.

I understand the hours of Needham Animal Hospital. I understand that a $15 fee will be applied if I pick up my dog after closing. I understand that my dog will be boarded overnight if I will be more than 15 minutes late to pick up. Regular boarding rates will apply.

I understand that, while Needham Animal Hospital takes careful precaution to avoid injury or illness to my pet, these risks do exist and that I am financially responsible for the associated veterinary care if my dog is injured or becomes ill as a result of attending daycare. I understand that, much like allowing a child to attend daycare or play a contact sport, risks of illness or injury are inherent and the associated medical costs are the responsibility of the parent (pet owner). I understand and agree that Needham Animal Hospital and its staff are not liable for any accident or injury that may occur. Examples of potential illness or injury include but are not limited to: Bite wounds, lameness injuries, intestinal parasites, oral papillomas, kennel cough or other infectious diseases. I understand that I am encouraged to discuss any concerns I have with the Needham Animal Hospital staff before I sign this release. I agree to let my dog participate in canine corporate play.

I understand that any problem, including but not limited to injury or accident, illness, or death, that occurs while on the Needham Animal Hospital premises will be treated as deemed best by the veterinarian on duty. Should the hospital not be able to reach me or my emergency contact within a reasonable amount of time, I authorize the attending veterinarian to administer the minimum medical treatment required to ensure the health and safety of my pet. I will also assume full financial responsibility for any subsequent expenses incurred. If I prefer for my pet to be treated at another veterinary hospital (in the event of injury) I understand that it is my responsibility to transport my pet to that facility for treatment.

If I prefer for my pet to be treated at another veterinary hospital (in the event of injury) I understand that it is my responsibility to transport my pet to that facility for treatment.

I certify that I am the owner or authorized agent for the owner of the above named pet and I authorize Needham Animal Hospital to admit this pet to their daycare facility. I accept the financial responsibility for this pet and I understand that payment is due at the time services are rendered.

I authorize Needham Animal Hospital to take photographs /video of my dog while participating in corporate play and I authorize the use of these photos in hospital marketing material and on social media websites.

Additional Comments

Signature(Required)

By Clicking The "Submit" Button, I Certify That I Am In Agreement With All Terms

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