Free Nursing Home Pet Policy Acknowledgment Form Template

Nursing Home Pet Policy Acknowledgment Form

Please review and complete this form to confirm your understanding and agreement with our pet policy guidelines.

Resident Information

Resident Name

    Date

      Room Number

        Assessor's Name

          Assessor's Job Title

            Pet Information

            Pet Type

            Indicate the type of your pet (e.g., dog, cat, bird):

              Pet Name

                Breed

                  Age

                    Weight

                      Pet Policy Guidelines

                      Please review each policy statement and check the box to acknowledge your agreement:

                      Pet Health and Vaccinations

                      • I agree to provide proof of up-to-date vaccinations and regular health check-ups for my pet.

                      • I understand that only healthy, non-aggressive pets are permitted within the nursing home.

                      Pet Hygiene and Cleanliness

                      • I will ensure my pet is clean, groomed, and free of pests (e.g., fleas, ticks).

                      • I agree to promptly clean up after my pet and maintain the cleanliness of shared spaces.

                      Pet Supervision and Control

                      • I understand that my pet must be supervised at all times within the facility.

                      • I agree that my pet will be kept on a leash or in a carrier when outside my personal room.

                      Pet Noise and Behavior Management

                      • I will ensure my pet does not cause excessive noise or disrupt other residents.

                      • I agree to address any behavior issues promptly, including any signs of aggression.

                      Liability and Responsibility

                      • I accept full responsibility for any damage or injury caused by my pet.

                      • I understand that repeated violations of this policy may result in the removal of my pet from the facility.

                      Emergency Contact Information

                      Primary Emergency Contact

                      Name

                        Phone number

                          Relationship to Resident

                            Alternate Emergency Contact

                            Name

                              Phone number

                                Relationship to Resident

                                  Acknowledgment and Signature

                                  • By signing below, I confirm that I have read, understood, and agreed to abide by the Nursing Home Pet Policy.

                                  Resident Signature

                                  Name:

                                  Date:

                                  Assessor Signature

                                  Name:

                                  Date:

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