Client Intake Form
Client Name: Address:______________________________
Home Number: Cell Number:__________________________
Local Emergency Contact: Emergency Phone:______________________
Veterinarian Name: Vet Phone:_____________________________
Clinic Name: Clinic Location:_________________________
Information About Your Home
Clean Up
Litter box location(s): ________________ Waste disposal container location:_______________
Cleaning Supplies Location: ______________________________________________________
Special Clean-up Instructions:
___________________________________________________________________________________
___________________________________________________________________________________
Security
Security System: Yes [ ] No [ ]
Security code and/or garage door code: ____________________________________________
Locks
Front Door Key [ ] Garage Door Key [ ] Garage Door Opener [ ]
Extra Key Location: _____________________________________________________________
Multiple Day and Night Care Instructions
(Please Complete the following if you require home care/pet sitting for multiple days.)
Date/Time of Client Departure:_______________ Date/Time of Client
Arrival:___________________
Check Mail: Yes [ ] No [ ]
Water Plants: Yes [ ] No [ ] Instructions:__________________________________________________
Take out garbage: Yes [ ] No [ ] Day of pickup and location:_____________________________
Any additional house maintenance? __________________________________________________
Information About Your Pet
(Please complete one sheet for each pet, if there are substantial differences)
Name:_____________________ Species:____________ Age(human years):_______
Breed:_____________________
Medications
Name of medication: _____________________ What is it for: _____________________
Dosage/times per day: _____________________
Special instructions:
_____________________________________________________________________________
_____________________________________________________________________________
__________________________________________________________________________
Behavior
Escape artist: Yes [ ] No [ ]
_____________________________________________________________________________
_____________________________________________________________________________
Fear Triggers/Physical Pain: Yes [ ] No [ ]
_____________________________________________________________________________
_____________________________________________________________________________
Aggressive History: Yes [ ] No [ ]
Special instructions:
_____________________________________________________________________________
_____________________________________________________________________________
Cues (commands) the dog knows (check all that apply):
Heel [ ] Sit [ ] Down [ ] Come [ ] Wait [ ] Crate [ ] Leave it [ ] Fetch [ ]
Additional cues:
________________________________________________________________________
Daily Routine
Meals Per Day:__________________________ Location of
food/treats:___________________
Feeding Times:_______________________ Quantity:_________________________________
Walking Times: _______________________Location of leash/collar:_____________________
Daily Routine: (wakeup, bedtime, playtime, etc, anything else you think I should know)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Payment Details*
Agreed-Upon Fee: $120 for every 24 hours
*Payment for half the total amount of time for which care is requested is due at the
commencement of services. The second half is due within 24 hours of the completion of care.
*Payment may be made via check, cash, Zelle ( 339-933-0648) , or Venmo ( @Eva-Catanzariti )
By signing below, the Client agrees that he/she has read the payment agreement and fully
understands and accepts its terms and conditions.
I have read the above and by signing below, I agree to the payment conditions listed above:
Client Signature _______________________________________
Print Client Name______________________________________
Date ____/_____/______