WAGGERZ'  LOUNGE
Day Care for Dogs
508 796-3015		 at the Summit
17 E. Mountain St
Worcester, MA 01606
 
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Waggerz’ Lounge Intake Form -- One form per dog please.
Please fill out this Intake Form or you may print this Intake Form and then fill it out and bring it to us when we meet.
How did you hear about us?
Your Information
Your Name:
Address:
City:
State:
Zip:
Home Phone:
Work:
Cell:
Email Address:   
  If we can’t get in touch with you who can we call? (Emergency Contact)
Name:
Address:
City:
State:
Zip:
Home Phone:
Work:
Cell:
  Veterinarian
Name:
Phone:
Address:
City:
State:
Zip:
  Pet Information
Name:
Sex:
Spayed/Neutered?
Age:
Birthday:
Breed:
Color:
Weight:
Microchip:
Microchip number:
Feeding schedule:
Brand & type of Food:
Where did you get this dog?
How long have you had him / her?
If you have not had him / her from puppyhood, what do you know of the dog’s prior history?
Are there any other animals in the household? (Species/Breed/Age)
Has your dog ever participated in daycare or played in off leash dog parks?
  About your dog.
Please describe your dog’s overall temperament.
How does your dog interact with other dogs? (Generally)
Has your dog ever bitten a person?
Has your dog ever bitten a dog?
Are there any particular types of people your dog seems to fear or dislike?
If yes please explain:
Has your dog ever tried to escape (home, backyard, vet, etc.)?
Does your dog jump fences?
Will your dog share water with other dogs?
Does your dog have any sensitive areas on his / her body?
If yes please explain:
Does your dog have any allergies?
Please list allergies:
Does your dog have any disabilities or health problems?
If yes please list:
Is your dog on tick and flea preventative?
Please click the "Submit" button to send us your information.
  The signature information below will be collected when you meet with us the first time.
  Signature of Owner:
  Date:
  Printed name:
  Waggerz’ Lounge:
  Date:
  Printed name: