Pet Care Agreement & Information Sheet

Pet Care Agreement

Owner

* Owner's Name

* Street Address

* City, State Zip

* Email

* Cell Phone

Home Phone

Work Phone

Emergency Contact

* Name

* Relationship to Owner

* Cell Phone

Home Phone

Work Phone

Veterinarian Information

* Veterinary Clinic Name

* Veterinarian Name

* Phone Number

Emergency Phone Number (if different)

Pet Name(s) -This includes all information provided on Pet Information Sheet(s) completed at the time of this agreement.

* Pet Name(s)

This is an Agreement between Countryside Pet Retreat and the pet owner whose electronic signature is signified by confirmation below (herinafter called "Owner".)

* 1. Owner agrees to pay the rate for the pet care provided in effect on the date pet is checked into Countryside Pet Retreat.

* 2. Owner further agrees to pay all costs and charges for special services requested and all veterinary costs for the pet during the period said pet is in the care of Countryside Pet Retreat. Owner agrees to be financially responsible for any required treatment for fleas/ticks if determined necessary by Countryside Pet Retreat.

* 3. Owner further agrees that the pet shall not leave the facility until all charges due are paid by Owner.

* 4. By Signing the Agreement and leaving pet with Countryside Pet Retreat Owner certifies to the accuracy of all information given about said pet. Countryside Pet Retreat reserves the right to deny admittance to Owner's pet for any reason at any time.

* 5. Countryside Pet Retreat shall exercise reasonable care for the pet delivered by the Owner to the pet care provider. It is expressly agreed by Owner and pet care provider that Countryside Pet Retreat's liability shall in no event exceed the lesser of the current chattel value of the pet of the same species or the sum of $400.00 per animal admitted. The Owner further agrees to be solely responsible for any and all acts or behavior of said pet while it is in the care of the pet care provider to include payment of costs for injury to staff or other animals or damage to facilities caused by the pet.

* 6. Owner specifically represents that he or she is the sole owner of the pet free and clear of all liens and encumbrances.

* 7. Owner specifically represents to Countryside Pet Retreat that to Owner's knowledge the pet has not been exposed to any contagious diseases within a thirty-day period prior to check-in. During the period of this Agreement Owner also agrees to notify Countryside Pet Retreat of any known exposures of pet to a communicable disease and hold pet out of attending Countryside Pet Retreat until pet is symptom-free for a minimum of thirty days or with written veterinary clearance. Owner further agrees to maintain currency of vaccinations as required by Countryside Pet Retreat policy.

* 8. All Charges incurred by Owner shall be payable upon pick-up of pet or when billed by Countryside Pet Retreat at address listed on Agreement. Countryside Pet Retreat shall have and is hereby granted a lien on the pet for any and all unpaid charges resulting from services provided by Countryside Pet Retreat. The Owner hereby agrees that in the event the charges are not paid when due in accordance with this Agreement Countryside Pet Retreat may exercise its lien rights upon fourteen days written notice given by Countryside Pet Retreat to Owner by certified mail to address shown on Agreement. Countryside Pet Retreat may dispose of pet for any and all unpaid charges at private or public sale in the sole discretion of Countryside Pet Retreat and Owner specifically waives all statutory or legal rights to the contrary. If such sale shall not secure a price adequate to pay such costs of pet care or other charges delinquent plus costs of sale then Owner shall be liable to Countryside Pet Retreat for the difference. All monies realized by Countryside Pet Retreat at such sale over and above the charges due and costs of sale shall be paid by to Owner.

* 9. If pet becomes ill or injured or if the state of the animals's health otherwise requires professional attention Countryside Pet Retreat in its sole discretion may engage the services of a veterinarian or administer medicine or give other requisite attention to the animal and the expense thereof shall be paid by the Owner.

* 10. The Agreement contains the entire agreement between the parties. All terms and conditions of this Agreement shall be binding on the heirs administrators personal representatives and assigns of the Owner and Countryside Pet Retreat.

* 11. Any controversy or claim arising out of or relating to this Agreement or the breach thereof or as the result of any claim or controversy involving the alleged negligence by a party to this agreement shall be settled in accordance with the rules of the American Arbitration Association and the judgement upon the award rendered by an arbitrator may be entered in any Court having jurisdiction thereof. The arbitrator shall as part of the award determine an award to the prevailing party of the cost of such arbitration and reasonable attorney's fees of the prevailing party.

* Confirmation/Electronic Signature I have read the above and agree to the terms

Pet Information Sheet

* Owner's Name

(Please fill out an individual sheet for each of pet)

* Pet Name

* Species Cat
Dog

* Gender Male
Female

* Condition Neutered
Spayed
Neither

* Age or Date of Birth

* Breed

* Weight

* Brief description of color and markings

Please fax current health certificate (shot records) to 1-888-607-8214.

Please answer Yes or No to the following questions. If the answer is yes, please provide details.

* Does your pet require a special diet?

* Does your pet require medication?

* Does your pet have any medical conditions such as seizures, allergies, injuries, growths, prone to hot spots?

* Does your pet require any special handling?

* Is your pet afraid of other dogs, cats, or humans?

* Is your pet aggressive toward other cats, dogs, or humans?

* Has your dog ever bitten anyone?

* Is your pet afraid of storms?

* Is your pet a known digger or climber?

* Please provide a brief description of your normal feeding schedule for your pet.

* Please provide the usual times during the day your pet has the availability to relieve themselves.

* Please provide any other information you feel would help us give your pet the proper care and attention during their stay with us?

* Verify