Nursing Home Pet Policy Acknowledgment Form
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
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I agree to provide proof of up-to-date vaccinations and regular health check-ups for my pet.
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I understand that only healthy, non-aggressive pets are permitted within the nursing home.
Pet Hygiene and Cleanliness
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I will ensure my pet is clean, groomed, and free of pests (e.g., fleas, ticks).
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I agree to promptly clean up after my pet and maintain the cleanliness of shared spaces.
Pet Supervision and Control
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I understand that my pet must be supervised at all times within the facility.
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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
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I will ensure my pet does not cause excessive noise or disrupt other residents.
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I agree to address any behavior issues promptly, including any signs of aggression.
Liability and Responsibility
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I accept full responsibility for any damage or injury caused by my pet.
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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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