The Pasadena Humane Society & SPCA


Pasadena Humane Society & SPCA 626-792-7151	Owner's Name: _________________________________________________ Addresss:______________________________________________________ Home Phone:___________________ Work Phone:______________________ Dog's Name: _____________________ Breed: ___________________ Age:________

	1. Has the dog boarded before? __________________________________ At the Pasadena Humane Society?_______________________________ If not at PHS, where? ________________________________________ 2. Have there been any problems when the animal boarded before? ________ Explain: ___________________________________________________ ___________________________________________________ ___________________________________________________ 3. Is the dog overweight? ________ 4. On any medication? ______ If yes, for what problem? ________________ Name of medication: __________________________________________ How often and when given: _____________________________________ Has it been on medication within the last 6 months? _________ If yes, for what problem? _________________ Name of medication: _________________________________________ How often and when given: ____________________________________ 5. Does the dog have any injuries, hot spots, irritations, skin problems, bandages, stitches or other problems our staff should be aware of? Explain: ___________________________________________________ ___________________________________________________ ___________________________________________________ 6. Is your veterinarian's office local to our shelter?______________________ Your vet's name and phone number: ______________________________ 7. What is your feeding routine for this dog? Time(s) of feeding: ________________ What brand: ________________ How many cups dry: ___________ Fed moisted with water? ________ How much canned: _________ 8. Is the dog used to being indoors most of the time? ______________ In air conditioning? _________ 9. How long will the dog be boarded? __________ Start date: _________ Time to be dropped off _______ Pickup date: ________ Time: ________ Note dogs need to be dropped off and picked up during our regular business hours: 9am-6pm Monday to Friday or 9am-5pm Saturday. We are closed on Sundays. 10. Emergency contact person (local): Name: ________________________ Phone______________________ Where to reach you while your dog is boarding with us: Telephone: ________________________________________________