Wufoo

Citizen Canine New Client Registration

Existing clients:
Please do not use this form to make reservations.
Please call (510) 562 1750 or email us instead.

Today's Date MM / DD / YYYY
Primary Guardian * First Last
Secondary Guardian First Last
Primary Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email Address *
Would you like our (low volume) e-newsletter?
Sign me up!

We send out a monthly newsletter with announcements and special offers. You may easily unsubscribe at any time.
Home Phone * ### - ### - ####
Work Phone ### - ### - ####
Mobile Phone ### - ### - ####
Preferred Contact Number
Home Phone Work Phone Mobile Phone
Referral
How did you hear about us? *
Vet Friend Professional Internet Other Yelp Facebook
Who may we thank for referring you?
Emergency Information

Please give us the name and details for a family member or close friend who is the emergency contact in the event we cannot reach you.
Emergency Contact First Last
Please give us the name and details for a family member or close friend who is the emergency contact in the event we cannot reach you.
Emergency Contact Phone ### - ### - ####
Veterinarian/Clinic Name
Veterinarian/Clinic City
Veterinarian/Clinic Phone
### - ### - ####
Requested Services

This form DOES NOT book your pet's stay.
Your reservation will not be confirmed until one of our customer service contacts you.
I am interested in scheduling my dog for:
Day Care Overnight Boarding

Please check all that apply.
I would like to drop my dog off on: MM / DD / YYYY
I would like to pick my dog up on: MM / DD / YYYY
If boarding more than one dog, they should
share a single family size room. stay in separate rooms.
Dog 1 Information

Your dog's details.
Dog 1 Name
Dog 1 Age
Dog 1 Breed / Color
Dog 1 Approximate Weight (lbs)
Dog 1 Gender
Female Female (Spayed) Male Male (Neutered)
Has your dog ever boarded before?
Is your dog comfortable meeting new people?
Has your dog ever bitten a person?
Is your dog social with other dogs?
Has your dog ever been in a fight with another dog?
Dog 2 Information

If you have a SECOND animal staying with us, please fill their details in here.

If not, please leave it blank, but don't forget to click the SUBMIT BUTTON at the bottom of the form to send us your information!
Dog 2 Name

A description of the section goes here.
Dog 2 Age
Dog 2 Breed / Color
Dog 2 Approximate Weight (lbs)
Dog 2 Gender
Female Female (Spayed) Male Male (Neutered)
Has your dog ever boarded before?
Is your dog comfortable meeting new people?
Has your dog ever bitten a person?
Is your dog social with other dogs?
Has your dog ever been in a fight with another dog?
Third Dog?

If you have a THIRD dog staying with us, we'll get those details when we speak to you by phone.

Don't forget to hit the SUBMIT button at the bottom of the form!
Thank You!

Thanks for taking the time to fill out our form.

Some people have reported that they get an error message after clicking the SUBMIT button. In the vast majority of cases the form has actually delivered your information to us (but it takes a while and the browser gets confused). If you do get an error, send an email to info@citizencanine.net and we'll double check for you. We look forward to talking to you about your visit to Citizen Canine!
Do Not Fill This Out

Wufoo

Citizen Canine New Client Registration

Referral

Emergency Information

Requested Services

Dog 1 Information

Dog 2 Information

Third Dog?

Thank You!