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|飼主姓名 |生日Birthday |□男Male |國籍 Nationality |飼主原居住國家 |

|Owner’s Name |yy/mm/dd |□女Female | |country of origin by owner |

| |19____/___/___ | | | |

|中華民國身份證 R.O.C. ID |電話Tel/Cell |

| | |

|護照號碼 Passport Number: |地址Address |

| | |

|入境日期時間Date/Time of import |戶籍地址□同上 □不同(辦理登記需填寫戶籍地址) |

犬貓隔離檢疫區 照護問卷 Questionnaire for Pet care

|寵物名pet’s name |性別sex |結紮neutered Y/N |出生年birth-year |品種breed |特徵 feature |

**請簡要描述寵物的個性、嗜好、以及可以了解的命令。

Briefly describe your pet’s character, hobby, and the commands.

1.寵物是否曾在台灣居住 Have your pets ever been in Taiwan?

□是Yes □否No

寵物是否曾在台灣作過寵物登記 Have your ever done microchip registration for them in Taiwan?

□是Yes □否No 登記人姓名_______________

2.檢疫期間飲食? Diet offered by quarantine in this period?

□區內乾糧 Dry food offered by quarantine

犬 dog □ 希爾斯Hill’s science diet □ 皇家 Royal canin

貓 cat □ 希爾斯Hill’s science diet □ 皇家 Royal canin

* 每日次數 Daily frequency________________ *每次總量 Quantity:________________

1小杯(1 small cup)=200cc=90grams 1大杯(1 large cup)=500cc=240grams

□自備乾糧 Dry food offered by owner

* 每日次數 Daily frequency________________ *每次總量 Quantity:________________

□自備其他 Others offered by owner _____________________________

3.檢疫期間是否有物品想要留給您的寵物? (藥品、玩具..等)

Anything want to leave for your pet?(drugs、toy...etc)

|物品名稱 Stuff for your pet |如何使用? How to use it? |

| | |

| | |

4.是否發生過特殊疾病或問題，需要醫師特別注意的? (請在勾選下方作重點描述)

Is there any problems or medical history that we should know? (Briefly describing below the table)

|行為behavior |□隨和型easy |□緊張型nervous |□攻擊型aggressive |

|飲食 diet |□挑嘴picky |□易吐vomiting |過敏 Allergy to |

| | | |過敏源: |

|耳Ear |□耳垢 ear wax |□發炎 inflammation |□其他others |

| |□左L □右R | | |

|眼 eyes |□發炎 inflammation |□乾眼 dry-eyes |□失明 blindness |

|口腔 mouth |口臭 halitosis |腫塊 mass |吞嚥困難difficulty swallowing |

| |牙結石dental tartar | | |

|皮膚 Skin |□外傷 wound □腫塊 mass |□抓或舔 scratch/lick |

| |位置site: |位置site: |

|骨骼bone |關節joint |脊椎spine |其他others |

|呼吸道 |咳嗽cough □喘 panting |氣喘asthema |

|Respiratory |頻率: | |

|排泄urinary/fecal |排尿問題urinary: |□排便問題 fecal: |

|慢性疾病 |□心肺cardiopulmonary |□腎臟 kidney |神經Nerve |

|chronic | | | |

|其他 other | |

若有持續使用或是備用藥物 請詳細註明藥物種類以及使用方式

Please make the prescription clearly if needed.

|疾病名稱 Disease |使用藥物 Medicine |使用方法頻率 frequency/pathway |

| | | |

| | | |

6. .跳蚤預防 Flea Prevention (每月一次，滴或噴在皮膚上 Applied on skin once per month)

□沒有預防 no prevention

□最後一次使用防蚤藥物Date of last application

使用日期Date:______/______/_____ (20yy/mm/dd) 使用品牌:_________________

特別注意：若您的犬貓有年老、兇猛、咬人或長期服藥等特殊狀況時，請您於犬貓至隔離場所時會合，以協助開箱、保定及確認晶片。您的運輸籠請於第一次探視動物時取回，隔離場所不負保管之責。

Notice：If your pets are old, violent, or taking medicine for chronic disease, please you visit the quarantine premise at the arrival of your pets, to handle the pets when cage opens. Please take back the cage when you visit your pet in the premise for the first time. The premise is not responsible for the cage storage.

填寫人簽名（Sign）：

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