Please enable JavaScript in your browser to complete this form.Owner Name *FirstLastCo-OwnerFirstLastClient (Owner) Date of Birth *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Spouse NameFirstLastPhone Number *Cell Phone Number *Work Phone NumberMay we contact you at work? *YesNoSpouse Phone NumberSpouse Work Phone NumberMay we contact your spouse at work?YesNoPet Information and Health HistoryAdditional / New Pet Name *Color / Markings *Male / Female — Select One *Male IntactMale NeuteredFemale IntactFemale SpayedHave you ever taken your pet to a Veterinarian? *YesNo Has your pet ever been vaccinated? *YesNo Do you have pet insurance (answer yes or no)? If yes, list name * Has or does your pet have any serious illness or injury (answer yes or no)? If yes, list: *Who is your pet's current veterinarian? *Pet Species and Breed/Mix *Date of Birth/Age *Is your pet microchipped (answer yes or no)? If yes, list microchip number *Is your pet allergic to any vaccines or medications? If yes, please listIs your pet on any medications, including Heartworm Prevention or Flea Control? If yes, list all medications *Has your pet been under anesthesia for any reason besides a neuter or spay? If yes, please explain: *Please provide us with your pet’s medical records. Thank youAdditional / New Pet NameColoring/ MarkingsMale / Female — Select One Male IntactMale NeuteredFemale IntactFemale Spayed Has your pet ever been vaccinated? YesNoDo you have pet insurance? If yes nameIs your pet on any medications, including Heartworm Prevention or Flea Control? Please listHas your pet been under anesthesia for any reason besides a neuter or spay? If yes, please explainPet Species and Breed/MixDate of Birth/ AgeHave you ever taken your pet to a Veterinarian? YesNoIs your pet microchipped? If yes, enter Microchip numberIs your pet allergic to any vaccines or medications? If yes, please list Has or does your pet have any serious illness or injury that we should be aware of? If yes please list.Who Is your pet's current Veterinarian?*All fees are due upon release of patient/guest. We accept all major credit cards (Visa, MasterCard, Discover, and American Express), Care Credit, cash and personal check ($30.00 fee for all returned checks). A deposit is required for major medical or surgical procedures. *We require a Driver’s License number on all personal checks. We also require personal identification when paying by credit card. If you elect not to give us this information you may pay by cash. *I acknowledge and accept full financial responsibility for all services rendered. I agree to pay any service charge or interest (18% per year) that will be assessed to any balance over 30 days past service date. In the event of default, I understand the balance due may be placed with a collection agency and I agree to pay the balance and the cost of collection fee. In the event of legal action, I agree to pay reasonable attorney fees and court costs. *I understand that Petsburgh Pet Care is not responsible for any accidental illness or injury incurred by my pet(s) beyond the control of the staff while staying or visiting at Petsburgh Pet Care unless due to the gross negligence or intentional misconduct of Petsburgh Pet Care. *By entering your email address in the above space, you give us permission to send reminders, promotions and other offers. You may unsubscribe at any time. *Please sign below Please select agree or disagree to the above paragraphs I AgreeI DisagreeI grant permission to Petsburgh Pet Care to use my pet’s name, information, picture and/or video for use in Petsburgh pet Care’s publications such as brochures, newsletters, display boards, website, or other electronic forms of media. Permission to use pet's photo and/or video:I AgreeI DisagreeWhy is your pet coming to Petsburgh? *Medical TreatmentGrooming apointmentBoarding ReservationsFor boarding only, please enter drop off and pickup dates *Please remember to send vaccination/ medical records. You can fax them 765-742-1730 or email ([email protected]) them to us. Thank you Signature of Owner or Authorized Agent: * Date: *Submit