Name: *

Email: *

Street:

Suite, Unit, Apt:

City:

State:

Zip Code:

Daytime Phone: *

Alternate Number:

Preferred Arrival Date:

Approximate Drop Off Time:

Preferred Departure Date:

Approximate Pick Up Time:

Pet's Name:

Dog or Cat:

Breed:

Birthday:

Weight:

Color:

Gender:

Spayed/Neutered:

AM:

Midday:

PM:

AM:

Midday:

PM:

Pet's Name:

Dog or Cat:

Breed:

Birthday:

Weight:

Color:

Gender:

Spayed/Neutered:

AM:

Midday:

PM:

AM:

Midday:

PM:

—$5.00 per walk

Would you like your pet to have one nature walk per day? Yes No

Would you like walks only on certain days during your pets stay? Yes No

What days?

—Please leave blank if you do not wish to have grooming/bathing for your pet. These services are additional charges.

Bath/Nails Yes

Bath/Trim Yes

Full Groom Yes

Nails Only Yes

Date pet should be done

Time of pick up:

Number to call when pet is ready:

Please add any additional information that would enable us to provide the best care possible:

Agree that my pet has been inoculated against all communicable diseases and is current with all the following vaccinations: Distemper, Hepatitis, Para influenza, Parvovirus, Rabies, and Bordetella (kennel cough).

Because we feel that we have provided a safe and secure environment for all pets; you the pet owner agree that Countryaire Kennels Inc. is not responsible for any injury that may occur during your pets stay at Countryaire Kennels Inc. You the owner also agree that Countryaire Kennels Inc. is not responsible for any of the following: damage from disease, death, theft, fire, injury to or from any other pets, running away, loss or damage done to personal property left with pet, or any other unavoidable mishaps.

We cannot diagnose or prescribe; however, if we note illness or any other warning signs that deserve attention, we will engage the services of a veterinarian. The pet will be taken to one of the following veterinarians: Germantown Animal Hospital, Thiensville/Mequon Small Animal or Wisconsin Veterinary Referral Center in Grafton. Any non-emergency situations will be handled over the phone with you the owner or the emergency contact left by you the owner and a veterinarian if needed. Any necessary veterinary charges or any other expenses paid by Countryaire Kennels Inc. must be reimbursed to Countryaire Kennels upon the owners return and before the pet is released from Countryaire Kennels Inc.