*2021_Check In / Client COVID-19 Certification

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Thank you for entrusting to us the health of your pet. We hope you and your family are staying safe and healthy.

Because of the safety precautions we have to implement in response to COVID-19, we are asking our clients to fill out this COVID-19 Certification Form to begin the check-in process. A part of our social distancing protocol is to primarily communicate with our clients by phone during the appointment.

We appreciate your kindness, patience, and cooperation.

Email *

Name of Person Bringing in Pet / Contact Number *

Pet's Info (Name, Dog/Cat/Other, Breed, Gender, Age) *

Client Health Disclosure *

Please check all that apply.

I do not have fever, coughing, and body aches for the past 14 days

I have not been diagnosed with COVID-19

I am not being treated for COVID-19 nor was treated for COVID-19

I am not in self-quarantine because of COVID-19

I have not been exposed to someone confirmed with COVID-19

I have not travelled outside of California for the past 14 days

I have travelled outside of California but it was more than 14 days ago

I was diagnosed with COVID-19 but have recovered (please indicate the date of diagnosis and the date when cleared as negative on "Other" below)

Other:

Required

Curb-Side Service - What to Expect During the Appointment

Were there any changes since the last visit?

Refill Request/s *

Please indicate if you need any refill for heartworm meds, flea/tick meds, prescription diets, etc. Write NONE if no refill request/s.

Signature / Date Signed *

By typing my full name below, it constitutes my acknowledgment that I have provided information to the best of my knowledge.

Send me a copy of my responses.

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