Magique

Dog Information Sheet

Entry Information

Registered Name____________________________________Call Name________________AKC#_____________________

Sire_______________________________________________Dam_______________________________________________

Birth Date________________Country_______________Breeder_________________________________________________

Breed______________________________Color/Variety_____________________Owner:____________________________

Vaccination Record (Current Vaccination Only)

Rabies_______________________________________________________________________________________________

Parvo________________________________________________________________________________________________

Kennel Cough_________________________________________________________________________________________

DHLPP______________________________________________________________________________________________

In Case of Emergency

Owner____________________________________Home #________________________Cell#_________________________

Co-Owner_________________________________Home #________________________Cell#_________________________

Friend____________________________________Home #________________________Cell#_________________________

Veterinarian_______________________________Office #________________________Emergency #___________________

Known Allergies - Other Health Related Information

Full Time Medications - If Any

Special Diet Required

In case of emergency, I, ______________________________________, owner of above mentioned dog, do herein give my permission to Dave Fleming to seek and provide medical treatment for my dog.  I further, accept all responsibilities for my dog while in the care of Dave Fleming, and/or his assistants.  If my dog should bite or other wise injure anyone, any and all liability for such shall be my responsibility.

                Signed                                                                                                                                    Date