Premium Pet Care Form Please fill in one application for each pet Service Type(Required)Select ServiceDog BoardingCat BoardingGrooming ServicesPremium Pet CareHave you ever boarded here before?(Required) Yes No has your dog ever been groomed here before(Required) Yes No First Name:(Required)Last Name:(Required)Email:(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone Number:Work Phone Number:Cell Phone Number:How did you hear about us? Internet Search Advertisement Friend Other If Other please specify:Emergency Contact First Name:Emergency Contact Last Name:Contact Phone Number:Contact Alt Phone Number:Comments:Pet's Name:Species:SelectCanineFelineOtherIf Other please specify:Breed:Comments:Add any descriptors you feel are applicable ex: long-hair/miniature/etcSexSelectMale neuteredFemale spayedMaleFemaleHeight (in):Weight (lbs):Color:Markings:Add any descriptors you feel appropriate. Ex 3 white feet.Tattoo or Microchip #DatePut an approximate date if unknown. MM slash DD slash YYYY Pet Veterinary Clinic:Please list the Veterinary Clinics official name.Are there any medical conditions or allergies that we should be aware of?Please specify any food or relevant allergies and list medical conditions we should be aware of or state N/A if not applicable.Please list any medications your pet is taking - Time given and dosageName the medication - the number of times per day you give it. The time of day you give it and the dosage given or state N/A if not applicable.Are there any other relevant details we should be aware of? Ex: Can clear 6 ft fences or stressed in thunderstormsList anything you think may be of importance in your pets stay or state N/A if not applicable.What brand and variety of food does your pet eat? Ex: Acana - Prairie Harvest:How many cups do you feed at each feeding and when do you feed?:What date do you want to drop off?What date do you want to pick up?If you have multiple pets, do you want them housed together?Do you have any questions you would like to ask us?What date do you want your dog groomed?Is there a second and third choice date that you can give us?Is this the first time this dog has been groomed? Yes No When was the last time this dog was groomed?Were there any issues with grooming in the past?Please let us know if the dog was scared, had clipper burn or stressed during a previous grooming?Type of grooming required?Please specify any particulars required. Ex:Bath and trim, Rake out dead coat, longer teddy bear, short face and feet, etcDoes the dog have any sensitivity to grooming products?Does the dog have reactions to certain shampoos or is there a particular product you prefer?Do you have any questions you would like to ask us?Your reservation is not confirmed until you have received a call confirming it. Expect the call within 1 business day and if you have not received it in that time, please call us at 403-931-3110 Please have your vet fax your pet's vaccination record to 403-931-3782 Or email a copy to boarding@beinnein.com
