Client Information Form

Client Information Form

To schedule an initial consultation, please fill out the form entirely. Please complete a separate form for each dog. Please answer the questions that follow as thoroughly as possible. All answers are confidential and will help me serve you better.
I will get back to you as quickly as possible with available time slots. Thanks very much!!
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Occupation
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
What is your availability? Please check all that apply:

Other
Type of Home
Yard
How did you hear about me?
Dog's Name
Dog's Date of Birth

MonthDayYear
If unsure, please write approximate date.
Weight (Kg)
Breed(s)
Where did you get your dog?
please list name of breeder or rescue organization if applicable
Photo of your dog:

Please upload a photo of your dog
Cancelof

Medical Information and History
Veterinarian's name (office name) and phone number:
Date and reason for last visit:
Date last vaccinated and vaccines administered:
Date of last blood test and abnormal findings if any:
Is your dog easily handled by vet staff?
Has your dog needed to be muzzled at the vet?
List any current health problems and medications:
If None, type None
List past health problems and treatments:
If None, type None
List any sensitivities or allergies including food and environmental:
If None, type None
Which flea and tick preventative do you use?
If None, type None
Which heartworm preventative do you use?
If None, type None
Is your dog spayed/neutered? If so, at what age?
If Intact, type No
Was your dog spayed/neutered for a behavioural or medical reason?

Medical Information and History