Intake Form

How did you hear about us?

Contact Information:

Emergency Contact Information:

Veterinary Information:

Pet Information:

MaleFemale

Spayed/neutered?

YesNoNot Sure

Microchip?

YesNo

Where did you get this dog?

How long have you had him/her?

If you have not had him / her from puppyhood, what do you know of the dog’s prior history?

Are there any other animals in the household? (Species/Breed/Age)

Has your dog ever participated in daycare or played in off leash dog parks?

Please describe your dog’s overall temperament.

How does your dog interact with other dogs? (Generally)

Has your dog ever bitten a person?

YesNo

Has your dog ever bitten a dog?

YesNo

Are there any particular types of people your dog seems to fear or dislike?

YesNo

If yes, please explain:

Has your dog ever tried to escape (home, backyard, vet, etc.)?

YesNo

Does your dog jump fences?

YesNo

Will your dog share water with other dogs?

YesNo

Does your dog have any sensitive areas on his / her body?

YesNo

If yes, please explain:

Does your dog have any allergies?

YesNo

If yes, please explain:

Does your dog have any disabilities or health problems?

YesNo

If yes, please explain:

Is your dog on tick and flea preventative?

YesNo

Is your dog on a worm/parasite preventative (ie. Heartgard, Sentinel, Advantage, Ivermectin/Pyrantel, etc.)?

YesNo

If yes, what is the brand?