Client Information Form

Happy Acres Client Information Form

Please review and fill out all information.

First Name

Last Name

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Phone

What do you need help with?

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone

Any person(s) beside yourself that has permission to pick up your dog:

Pet Information

Pet 1 Name

Pet 1 Age

Pet 1 Breed

Pet 2 Name

Pet 2 Age

Pet 2 Breed

Medical Information

Veterinarian/Clinic

Phone

Is your dog on:

Heartworm Preventative

Flea/Tick Control

Any other medication (please list below)

Any previous medical issues or conditions our staff needs to be aware of?

Any other information you would like us to know?

Please include a photo of your dog.

Upload Image

Copy or screenshot of your dogs Rabies Certificate. Puppies under the age of 16 weeks are too young for the Rabies vaccination. Please attach what shot records you have.

Upload File

Copy or Screenshot of your dogs Shot Records

Upload File

Per Iowa Code 21—67.7(162). All animals entering this facility must have proof of and be current on all vaccinations including Rabies, Distemper, and Parvo. This licensed facility is required to keep this Veterinary record.

Please check to indicate you that understand we must receive your shot records and rabies certificate 72 hours prior to class starting or your money will be refunded minus a $25.00 administration fee.

In the event of a medical emergency for your dog, if we are unable to reach you or your veterinarian your dog will be taken to and treated at Winterset Veterinary Clinic. All charges incurred are the responsibility of the owner.

Your Signature

Thank you for submitting all your information!

Happy Acres Client Information Form

Emergency Contact Information

Pet Information

Medical Information

Happy Acres

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