Jim Schuster - Certified Elder Law Attorney

PET INFORMATION SHEET

Name of owner:________________________________

Name of pet:__________________________________ Place your pet’s photo here

Species/breed:_________________________________

Sex:_________

Spayed/Neutered:______________________________

Birth date or approximate age:_____________________

Indoor or outdoor:______________________________

Color:_______________________________________

Other forms of identification or description (microchip, tattoo, identifying marks, etc.): ___________________________________________________________________________________

VETERINARY AND HEALTH INFORMATION

Name of Veterinarian/Clinic:______________________________________________________________

Address:_____________________________________________________________________________

Phone:____________________________________ Fax: _____________________________________

Location of veterinary records other than above facility:__________________________________________

Current medications and instructions:________________________________________________________

___________________________________________________________________________________

Other health considerations: (chronic illness, allergies, injuries): ____________________________________

___________________________________________________________________________________

CARETAKING INFORMATION

Name of temporarycaretaker or kennel:____________________________________________________

Address:____________________________________________________________________________

Phone:____________________________________ Fax: _____________________________________

Name of permanentcaretaker or kennel:____________________________________________________

Address:___________________________________________________________________________

Phone: ___________________________________ Fax: _____________________________________

Description of typical daily routine for the care of the pet:________________________________________

___________________________________________________________________________________

Accommodations (where the pet sleeps, where the pet stays during the day):_________________________

___________________________________________________________________________________

Diet (brand and type of food, instructions for mixing, feeding times): _______________________________

__________________________________________________________________________________

Recreational activities ( walks, games, favorite toys): __________________________________________

__________________________________________________________________________________

Persons, objects or circumstances that the pet does NOT like (men, women, children, loud noises, water, etc.)

___________________________________________________________________________________

Circumstances that may cause the pet to bite:_________________________________________________

___________________________________________________________________________________

Any behavioral problems (barking, chewing, separation anxiety, heel nipping): ________________________

___________________________________________________________________________________