Puppy Party Registration

Pet's Information

Pet's Name:

DOB:

Breed:

Color:

Sex:

Female
Male
Unknown

Neutered
Spayed

Identifiers (Microchip #, Tattoos, Special Marks, Declawed, AWC #):

Acquired at what age:

Origin:

Has your pet ever traveled/lived outside of Alaska?

No
Yes

(States and approximate dates)

Who is your puppy's veterinarian?

Date of Last Deworming:

Date of Last Bordetella (Kennel Cough) Vaccination:

Date of Last Canine Distemper/Parvo/Corona Vaccination:

Date of Last Rabies Vaccination:

Food:

Dry
Soft/Moist
Canned

Brand(s):

Treats/Supplements:

Do you currently have Pet Insurance?

Yes
No

Pet Insurance Company:

Please tell us what you would like to accomplish in this class:

How did you become aware of our puppy parties?

Client Information

The following contact information is used for CVAC use only, we honor your privacy & security.

Name*

First Last

Co-Owner Name

First Last

Spouse
Parent

Mailing Address:*

Street Address Address Line 2 City State ZIP Code

Residence address same as mailing?

Yes
No

Residence Address:

Street Address Address Line 2 City State ZIP / Postal Code

Primary Phone #:

Home
Cell
Work

Alt. Phone:

Home
Cell
Work

Alt. Phone:

Home
Cell
Work

E-mail Address:

Authorization*

I agree to the terms and conditions.

In consideration of the acceptance of this registration, and the holding of classes, and the opportunity to have my dog participate, I agree to hold College Village Animal Clinic, Inc. harmless from any claim for the loss or injury. I personally assume all responsibility and liability for any such claim. By signing this form I am allowing College Village Animal Clinic to use class videos and photos for marketing materials, including the clinic website and social media pages.

Comments

This field is for validation purposes and should be left unchanged.

...your family's other doctors

PHONE:

ADDRESS:

HOURS OF OPERATION: