Owner name: __________________________________________________________________________

Address: _____________________________________________________________________________

Home Phone: __________________________________________________________________________

Work Phone (w/area code): _______________________________________________________________

Cell Phone (w/area code): _________________________________________________________________

In the event that the owner is injured, hospitalized or otherwise unavailable, please contact one of the following (spouse, nearest relative, neighbor, or friend) to provide care for the pets in this household:

     Name             Phone (w/area code)             Alternate Phone (w/area code)             Relationship

1) ____________________________________________________________________________________

2) ____________________________________________________________________________________

3) ____________________________________________________________________________________

Name: ________________________________________________________________________________

Clinic Name: ____________________________________________________________________________

Address: ______________________________________________________________________________

Phone (w/area code): _____________________________________________________________________

Total number of pets in this household: Dogs _____ Cats _____ Birds _____ Other _____________

      Name of Pet                                 Description: (sex, age, species/breed, color/special markings, personality traits)

1) ____________________________________________________________________________________

2) ____________________________________________________________________________________

3) ____________________________________________________________________________________

4) ____________________________________________________________________________________

Pet(s) Requiring Medication or Special Diet (attach separate sheet if needed):

     Name of Pet                  Medicine name, dosage, reason needed, and location where it can be found in the home

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Food, bowls, leashes, bedding, and other pet supplies can be found in the following locations of the home:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Until other caregivers arrive, the following pet sitting service can be contacted to provide short-term care for the pets in this household:

Name of Petsitting Service: _______________________________________________________________

Name of Pet Sitter: ______________________________________________________________________

Work Phone (w/area code): _______________________________________________________________

Cell Phone (w/area code): ________________________________________________________________

In the event of the owner’s death or incapacitating illness, are there specific instructions for the pet’s long-term care (designated caregiver/guardian, trust, will, etc.)? Yes ____ No ____

If yes, please give contact information below (attorney, guardian, etc.):

Name: ________________________________________________________________________________

Address: ______________________________________________________________________________

Phone: ________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________