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Willow Creek Pet Center

Stay n’ Play Day Care Medical History Form

In order for us to provide the best experience and care possible for your dog while in Willow Creek Pet Center's Stay N Play please provide us with the following information.

Name of Dog:
Client Name:
File #:

Has your dog been spayed or neutered? YesNo

Please indicate if your dog has any of the following medical conditions:

  • Seizure Disorder: YesNo
    • If yes, how often does your pet experience seizures?
    • When was his/her last seizure?
    • Is he/she on medications for seizures: YesNo
    • If yes, name of medication and dosage:
  • Diabetes: YesNo
    • If yes; What insulin?
    • Dosage:
    • How often?
    • When is it given?
  • Addison's Disease: YesNo
  • Arthritis: YesNo
  • Hip or Elbow Dysplasia: YesNo
  • Cushing's Disease: YesNo
  • Auto Immune Diseases: YesNo
  • Bleeding Disorders: YesNo
  • Kidney Disease: YesNo
  • Orthopedic Surgeries/Issues or Deformities: YesNo
  • Liver Disease: YesNo
  • Blind or Missing an Eye: YesNo
  • Deaf or Hard of Hearing: YesNo
  • Spinal Issues/Back Problems: YesNo
  • Missing a Limb or Appendage (toe, ear etc.): YesNo

Recent Surgeries:
Previous injuries (fractures/knee surgery)
Food allergies:
Are there any other medical conditions?

Please the list names of any medications and dosages:

  • Medication #1:
  • Medication #2:
  • Medication #3:

I understand that by signing this form I have informed Willow Creek Pet Center of ALL medical conditions and medications related to my dog. I understand that by allowing my dog to participate and attend Stay N Play there is an increased risk related to medical conditions and medication that could include illness, injury or death. I understand that by signing this form I release Willow Creek Pet Center and all of its associates from any liability if my pet becomes ill, injured or dies from complications related to their known and unknown medical conditions while participating in and attending Stay N Play.

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