Shadow's Retreat
DOG’S NAME________________________________TODAY’S DATE_________________________________
Has your dog been boarded or in day care before? Yes___ No___
If yes, when, where, for how long and how did he/she behave? _________________________________________________________
___________________________________________________________________________________________________________
Has your dog been socialized with other dogs? Yes___ No___
Has your dog been socialized with men and women? Yes___ No___
Is your dog aggressive with strangers? Yes___ No___
Is your dog aggressive on walks towards people? Yes___ No___
Is your dog aggressive on walks towards other animals? Yes___ No___
Is your dog spayed or neutered? Yes___ No___
Does your dog have any allergies? Yes___ No___
If yes please list them. _________________________________________________________________________________________
Is your dog on a flea treatment? Yes___ No___
If yes what kind. ______________________________________________________________________________________________
Has your dog been in training classes and/or private training? Yes___ No___
If yes by whom, when, and for how long? ___________________________________________________________________________
Has your dog been to a dog park before? Yes ___ No ___
How did he behave? ___________________________________________________________________________________________
__________________________________________________________________________________________________________
PROBLEMS? Please indicate yes or no (Y or N):
Dog Aggressive__ People Aggressive__ Toy/Food Aggressive ___ Chews__
Digs__ Barks__ Runs Away__ Unruly__
Escapes__ High Jumper__ Shy__ Afraid of Noises__
Toy Possessive__ People Possessive__ Separation Anxiety__ Stool Eater__
Picky Eater__ House Soils__ Jumps Up__
Growled at someone ___ Bitten someone ___ Other (Explain, please) _______________________________
Knows commands ______ List commands __________________________________________________________________
Is there anything else we need to know about your dog? _______________________________________________________________
How did you hear about us? _____________________________________________________________________________________
Evaluation Form
BOARDING INFORMATION
DATES TO BOARD From _______________AM or AFT To: ___________________AM or AFT TODAY’S DATE:____________
OWNER Last Name ____________________________________ First Name __________________________________
OWNER ADDRESS Street____________________________________________________________________________________
City ____________________________________ State _______________________ Zip _________________
PHONES Home _______________________ Cell _____________________________Office_______________________
EMAIL ADDRESS _________________________________________________________________________________________
EMERGENCY Contact _______________________________________________ Phone _____________________________
PET INFORMATION Name ___________________________ Breed ____________________________________ Age _________
Weight ________ Color ______________________ DOB: __________ Sex: ___Spayed/Neutered circle one
VACCINATION Rabies _____________________ D.H.L.P.P. _____________________ Influenza ______________
RECORD
(Please list Lyme ______________________ Bordetella _____________________ Fecal Exam ____________
Expiration Dates)
A copy of record Heartworm __________________ Flea/Tick _____________________ Worming__________________
Must be provided.
VETERNARIAN INFO Name _______________________________________________________ Phone ____________________
ANY HEALTH ISSUES ________________________________________________________________________________________
FOOD Amount ___________/cups Check if applicable ___AM __PM CAN HAVE TREATS (Yes/No) _____
FOOD PROVIDED BRAND________________________________________________________________________________
ADDITIONAL SERVICES _______________________________________________________________________________________
NEEDED ________________________________________________________________________________________
ANYTHING YOU THINK ________________________________________________________________________________________
I NEED TO KNOW
TERMS
All dogs must be up to date on all vaccinations or provideTiter Certificate from Veterinarian. A copy of the medical record must be
provided prior to boarding. If not provided, you authorize Shadow’s Retreat to administer any necessary vaccinations and agree to pay
the costs (DHPP $30.00 & Bordetella $30.00). Bordetella must have been given within the past six months, if not it will be given upon
check-in.
Shadow’s Retreat will provide your dog with a safe and secure environment and will properly feed, brush, and groom your dog as
requested or needed. If there is an emergency situation, your pet will be taken to your vet, if possible, or to the closest vet. If it is an
after hours-emergency situation, your pet will be taken to Leesburg Emergency Hospital. Owner is responsible for any and all costs
incurred (this includes but is not limited to injuries or illness to owner’s dog, injury or damage caused by owner’s dog to property or
an individual, costs incurred for transportation to & from facility, etc). By signing this form you give permission for Gene or
Carla Robey to act on your behalf to obtain medical care or other care as needed. Shadow's Retreat, owners and employees,
will exercise all due and reasonable care to prevent injury, illness, death or loss to your pet. However, in the event of injury, illness,
loss or death, you will not hold Shadow's Retreat or owners or employees liable for such injury, illness, loss or death under any
circumstances. Under no circumstances will we be responsible/liable for any charges that arise from such illness, injury, loss or death.
I accept cash or checks, VISA, MasterCard & Discover. There is a 3% surcharge for using credit cards.
There is a $35.00 fee for returned checks. If necessary to take legal proceedings to collect a debt, the owner is responsible for
all legal fees. The owner affirms that all facts and information regarding the Ownership of the dog, the dog’s veterinary care,
the dog’s general health, behavior and habits, and exposure to any canine disease are true and accurate.
By signing this form the Owner affirms that he/she has read this form in its entirety, releases Shadow’s Retreat its owners
& employees from any and all liability and agrees with the contents.
OWNER SIGNATURE ___________________________________________________ DATE ___________________________________
Downloading this form does not automatically make a reservation. You must call us at 703-327-6454 to make/confirm this reservation.
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Copyright 2019 Shadow's Retreat LLC Leesburg, Virginia