Intake Form

Owner's First Name

Owner's Last Name

Street Address

City

State

Zip Code

Phone

Email Address

Where did you hear about us?

Vet's Name

Vet's Number

Any children in the home? Any children in the home? Yes No

Total number of occupants in the home?

Do you have any other pets? Do you have any other pets? Yes No

Dog’s name

Dog’s Gender Dog’s GenderMaleFemale

Spade or neutered? Spade or neutered? Yes No

Is your dog current on vaccinations? Is your dog current on vaccinations? Yes No

Breed

Dog’s Birthday or Approximate age

What brand of food does your dog eat?

Does your dog have any food allergies? If so, list them here.

Does your dog take any medications? If yes, list them here.

Does your dog have any past injuries or current conditions? If so, list them here.

Does your dog have any fears or phobias? Does your dog have any fears or phobias? Yes No

List your dogs fears (If Applicable)

List any sensitive areas on your dogs body

How does your dog react to strangers?

Rate your dogs energy level. 1 being very mellow and 10 being out of control. Rate your dogs energy level. 1 being very mellow and 10 being out of control.12345678910

Does your dog show any destructive behaviors when you are not at home? (i.e. chewing up furniture, chewing up door facings or windows ceils, causing damage to crate, etc.) Does your dog show any destructive behaviors when you are not at home? (i.e. chewing up furniture, chewing up door facings or windows ceils, causing damage to crate, etc.) Yes No

Is your dog aggressive on a leash? Is your dog aggressive on a leash? Yes No

Has your dog ever bitten anyone? Has your dog ever bitten anyone? Yes No

Does your dog jump up? Does your dog jump up? Yes No

Does your dog bark excessively? Does your dog bark excessively? Yes No

Does your dog dig? Does your dog dig? Yes No

Is your dog aggressive around food/toys? Is your dog aggressive around food/toys? Yes No

List any specific issues you would like to work on.