Roman’s Holistic Pet Service

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First-Time Boarding Questionnaire
Mail to: 1 North str. Cos Cob, CT-06807 Or SCAN and e-mail with certified web signature to Owner’s Name ___________________________________________________________________________ Home Address _____________________________________ City ________________________ZIP________________ Home Phone_________________ Cell _________________ Work Phone __________________ E-mail address ____________________________________________________________________________ Local emergency contact name and number _____________________________________________________________________________ Dog’s Name ____________________________________ we call him___________________________ Dog’s Breed ___________________________ Mixed with____________________ Not sure_________ Date of Birth/Age _____ Dog’s Sex __M/Neutered** __F/Spayed ** Vet name and phone # ______________________________________________________________________________ Any known allergies or illnesses? ______________________________________________________________________________

Roman’s Holistic Pet Service
Page 2 List any and all present medications taken by your dog (including heartworm, flea and tick prevention) ______________________________________________________________________________ List any surgery your dog has gone through: ______________________________________________________________________________ What does your dog eat? ________________________ Wow often and how much? _________________________ We ask the following questions to better understand your dog: Has your dog ever bitten, or attempted to bite, another animal or person? ______________________________________________________________________________ Has your dog shown any aggressive tendencies regarding food or toys? ______________________________________________________________________________ Does your dog have a “quiet” command? ______________________________________________________________________________ Is your dog potty trained? _____________________________________________________________________________

What is your dog’s command to go potty? ______________________________________________________________________________

Roman’s Holistic Pet Service
Page 3 What are your dogs’ favorite toys? ______________________________________________________________________________ What kinds of games does your dog like to play? ______________________________________________________________________________ List all the places your dog sleeps ______________________________________________________________________________ How many hours does your dog spend indoors?___________________ outdoors? __________________ How, when, and at what age did your dog join the family? ______________________________________________________________________________ Did you own a dog/dogs previously? If yes, what breed? ______________________________________________________________________________ How does your dog react to small, furry animals, such as small dogs, rabbits, squirrels, cats? ______________________________________________________________________________ Is your dog fearful or reactive around certain kinds of sounds, noise, dogs or people? ______________________________________________________________________________

** Although we do not require that all dogs be spayed or neutered, we do reserve the right to turn away any dog we feel will have a disruptive influence on the kennel environment, and sometimes that is due to the fact that they are not altered or in the case with females, in estrus.

Roman’s Holistic Pet Service
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Please check all that apply:
_____ Separation anxiety _____ Toy/food aggression _____ Sensitive to touch _____ Fearful of children _____ Fearful of men or women (circle which) _____ Mouthiness (not considered biting) _____ Fear of thunder _____ Digs _____ Destructive chewing (bedding, etc.) _____ Grabs food from table ______Other please describe ___________________________________ _ ___________________________________ _

How did you hear about us or whom may we thank for the referral? ___________________________________________________________________________ If your dog(s) arrives on the property with fleas or ticks they will be bathed and an additional charge of $15.00 or more will be added to your bill. If your dog(s) has ticks and requires quarantine or a vet visit, you agree to pay for all charges involved. Has your dog ever boarded before? How was the experience for you and your dog? ______________________________________________________________________________ ______________________________________________________________________________ Are there any other special needs, comments or information Holistic Pet Service should be aware of to make your dog’s stay with us the best experience possible? _____________________________________________________________________________

Roman’s Holistic Pet Service
Page 5 Would you like us to provide any “Additional Holistic Services” while your dog is in our care? Holistic menu (“fresh prepared” selected organic vegetables, rice, lean Angus beef, hand or lap feed) $10 Holistic complete body care (washing, ears, nails) Boarding bed rental Personal Antlers $ 80 $ 10 $25

30-45 minute massage, acupressure and sound sessions are available at a boarder’s discounted rates Massage Therapy 15 minutes $55 _____ (includes 1 h walk in distress mode and feeding) Sound-DNA Stimulation 15 minutes $10 ___ (supports behavioral therapy and healing) Cardio walk $35 per hour ______ (additional challenges while walking / working) one dog at a time, breed specific Good citizen walk $45 per hour _____ (preparation for good citizen test – generally a good experience for anti-social dogs.) Prices are based on the need for one or two people to perform the selected service. We suggest bringing your dog’s favorite toys, blanket, rug or anything else that will make him/her feel more at home. Most dogs have fewer issues with tummy upset if they are fed their normal food. However, we are happy to provide dry food meals for an additional $3/day using Holistic Pet Service preferred food (Orijen dry food mixed with homemade rice boiled in beef stock soup and organic meet and vegetables - hand prepared with love) . Holistic Pet Service agrees to exercise due and reasonable care and to keep our premises sanitary and property enclosed. You dog will be fed and watered and exercised properly and regularly, and housed in clean, safe quarters. All dogs are boarded, trained, or otherwise handled or cared for by us without liability on our part of loss or damage from disease, death, running away, theft, fire, injury to persons, other dogs, or property by said dog, or other unavoidable causes, due diligence and care having been exercised.

Roman’s Holistic Pet Service
Page 6 Dogs will not be released without full payment. Owner agrees to pay all charges in full, being reasonable and consistent as determined by Holistic Pet Service, including any expenses incurred by Holistic Pet Service to recover payment in full. If your dog becomes ill or the state of the dog’s health reasonably demands quick action, we shall have the right to pursue veterinary care and administer medicine provided by the veterinarian. Holistic Pet Service has the right to make this judgment call and Owner agrees to pay for all veterinary expenses, being reasonable in amount (see below). If your dog is found to have a flea or tick infestation, he/she will be bathed and dipped at the owner’s expense to avoid infesting others in the kennel. Please provide the maximum medical expense we are authorized to incur on behalf of your dog. Do you have a Pet insurance plan? ______________________________________________ Please keep in mind that emergency surgery for bloat and similar conditions can be as much as $2500. YES I UNDERSTAND ____________ You understand that your dog will be allowed to play with other dogs while staying at Holistic Pet Service, if there is no exhibition of animal aggression. You understand that dogs are not wholly predictable and will not hold Holistic Pet Service or its employees, landlord, or independent contractors responsible for any and all loss, damage, and/or injury to your pet(s) resulting from the behaviors displayed by any of the dogs on the premises of Holistic Pet Service property. YES I UNDERSTAND _____________ You do have the right to request that your dog not be allowed to play and/or socialize with other dogs and this request will be honored by all staff and management at Holistic Pet Service at a attritional charge of $35 per day In the unlikely event that your dog becomes critically ill or passes while in our care, and you cannot be reached, please indicate how you would want us to handle the situation: Keep on life support as long as possible? ___ Yes ___No Have autopsy performed? ___ Yes ___No

Roman’s Holistic Pet Service
Page 7 Have vet do a private cremation and save ashes? ___ Yes ___No Have vet dispose of body? ___ Yes ___No Have vet save body for burial? ___ Yes ___No Owner’s Signature ___________________________________________________________ Date __________________________________________

WE DO NOT TAKE HUMAN AGGRESSIVE DOGS! Owners of any dogs which display human aggression will be asked to have the dog removed immediately from the boarding home. We are not talking about fearful growls or mouthing. The staff is experienced and trained to deal with all types of dogs, but it if for the safety of all concerned that we not keep truly aggressive dogs, with the will and tendency to attack, on our grounds.

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