Intake Form for Swimming at Unsinkable Dogs

Unsinkable Dogs K9 Warm Water Swim Center

Intake Form

PRINT LEGIBLY PLEASE


 

OWNER NAME___________________________________________________     DATE____________________

 

ADDRESS_____________________________________________ CITY_________________________________

 

STATE__________________________ ZIP__________ EMAIL________________________________________

 

BEST PHONE [____]____________________ 2ND BEST PHONE [____]________________________________  

 

DOG NAME_________________________________ APPROX. AGE _______  COLOR _____________________

 

BREED/X__________________________ GENDER_____ ALTERED   Y___   N ___ APPROX WEIGHT_______ 

 

PRIMARY VETERINARIAN NAME ___________________________ CLINIC____________________________

 

PHONE ___________________________CITY ___________________________________ STATE ____________ 

 APPROX. LAST VISIT DATE ________________ APPROX. LAST VACCINATION DATE ________________

IF APPLICABLE

SPECIALTY VETERINARIAN NAME __________________________ CLINIC____________________________

 

PHONE____________________________CITY ___________________________________ STATE ____________ 

 

APPROX. LAST VISIT DATE ________________ PROCEDURES? _____________________________________

 

_____________________________________________________________________________________________

 

CURRENT MEDICAL DIAGNOSIS IF ANY _______________________________________________________

 PRIOR SURGERIES____________________________________________________________________________

Temperament History

**************Use back of form if necessary**************

What is your dog’s likely response to water?

 

Is your dog reactive to other dogs and if so, please describe?

 

Is your dog reactive to strangers and if so, please describe?

 

What is your dog’s typical response to being handled by strangers?

 

Circle all that apply:     submissive        shy       relaxed              pushy               nervous             cautious

  always friendly        friendly once familiar        hyper/busy/lots of “drive”         unpredictable       

 

Does your dog like toys, and if so, what?

 

Does your dog retrieve, and if so, what?                          Does your dog like treats, and if so, what?         


 

Please read the following statement initialing each, and sign your name:

 

____I understand that my dog needs to be clean and well-brushed prior to swimming at Unsinkable Dogs.  A good brushing done one or two days prior to swimming will help minimize clogging of drains and filters, no matter what length my dog’s hair is.

 
____I understand that it will be far easier and safer for my dog as well as the person working with my dog if I keep my dog’s nails trimmed regularly, including filing or using a grinder to smooth off rough edges.

 
____I understand that I should not feed my dog a meal within 4 hours of swimming at Unsinkable Dogs, and that this helps prevent unwanted deposits from either end of my dog!

 
____I know that if my dog has a bowel accident in the pool, that the pool will be closed. As a result I may be responsible for some of the costs to Unsinkable Dogs including loss of income, the labor to do a water exchange and to sanitize the pool. I know I can ask my Veterinarian to show me how to help my dog evacuate her bowels if I am concerned about this possibility.

 
____I understand that even waterproof flea treatments are not waterproof and that 7 days must elapse between any topical flea treatment and taking my dog to swim at Unsinkable Dogs. 


 What is your primary reason for coming to Unsinkable Dogs?

 

 

What outcome do you hope swimming your dog will achieve?

 
 

 

How did you find out about Unsinkable Dogs?

 

   

SCHEDULING

 As we are just starting out, and some of our staff travels a fair distance to come assist dogs in the pool, we will be open on a limited basis. As our schedule fills (we anticipate that this will happen fairly rapidly) our open hours will increase. In an effort to accommodate your scheduling needs as closely as possible, please check ALL THAT APPLY.

 

I want a practitioner in the pool with my dog and prefer:  

Water TTouch___  Water Reiki___ either___  Assisted Swim___

 

All times I am available:             Evenings after ____      Mornings____    Afternoons____ 

 

All days I am available: Monday__ Tuesday__ Wednesday__ Thursday___ Friday__ Saturday__ Sunday___
 

I am available any day and any time___

 

My time preference once schedules solidify and the pool is open all day 6 days a week would be:

 

 


By signing below:

I/we agree to hold harmless and indemnify Joyce’s Dog Obedience Services Inc. [JDOSI], Unsinkable Dogs: K9 Warm Water Swim Center [UD], Joyce Biethan, the owner of the aforementioned company,  as well as her agents, employees, volunteers, successors and assigns from any claim for loss or injury which may be alleged to have been caused directly or indirectly to any person or thing by the act of this dog while in or upon the premises or grounds or near any entrance thereto, and I/we personally assume all responsibility and liability for such claim.

I/we  further agree to hold the aforementioned parties harmless from any claim of loss of this dog by disappearance, theft, death or otherwise, and from any claim of damage or injury to the dog, caused or alleged to be caused by the negligence of the parties aforementioned, or by the negligence of any other person or any other cause or causes. 

I/we hereby assume the sole responsibility for and agree to indemnify and hold the aforementioned parties harmless from any and all loss and expenses (including legal fees) by reason of the liability imposed by law upon any of the aforementioned parties for damage because of bodily injuries, including death at any time resulting there from, sustained by any person or persons, including myself (ourselves), or on account of damage to property, howsoever such injuries, death or damage to property may be caused, and whether or not the same may have been caused or may have been alleged to have been caused by negligence of the aforementioned parties or any of their employees, agents, or any other person.

I/we certify that the above referenced dog is up-to-date on all vaccinations, is parasite-free, has had no contagious illness or condition in the last sixty days and has not harmed or shown aggressive or threatening behavior towards any person or any other dog that has not been disclosed to the owner of Joyce’s Dog Obedience Services Inc. and UD.

I/we Undersigned, have read this RELEASE and understand all its terms.  I/we execute it voluntarily and with full knowledge of its significance. This agreement has no time limit and is valid and enforceable for any and all future activity with my dog[s].

 

SIGNED: __________________________________ DATE: ______________________

 

Emergency Contact:

 

Name_________________________Phone______________Relationship___________

 

 

 

 

MAIL / FAX FORM TO:

 

Joyce Biethan
Unsinkable Dogs
20413 NE 29th Ave
Ridgefield WA 98642

206-819-7297

Fax 360-727-3479