Behavior Rehabilitation Form
Ubera Rehabilitation
A. Client
Name of owner :
First Name
Last Name
Email :
example@example.com
Phone number :
Address :
Client Identity Card (KTP / KITAS / KITAP)
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Who will be part of the training? Are all members aware?
Are you ready to change your daily habits for the good and well-being of your dog?
How did you hear about us?
Instagram
Friends / Family
Google
Other
B. Dog
Name :
Gender :
Male
Female
Breed :
Age :
Weight (Kg) :
Spay or Neuter
Spayed (female)
Neutered (male)
Vaccinations :
Rabies
Distemper
Bordetella
Parvovirus
Date of last vaccination :
Date of last flea meds :
Allergies :
Vet information :
Other medical considerations / cautions? (Please specific if yes, what type of medication, etc.) :
Where did you get your dog from?
Any previous training? Y/N (Please specific if yes, what type of training, etc.)
C. Background
Complete dog history from client
Who chose the dog and is the whole family supportive?
Is anyone scared of the dog? Why?
Does your family have other dogs/animals in the house?
D. Behavior
Daily routine :
Is your dog Potty-trained?
No
Yes
Is your dog Leash-trained?
No
Yes
Is your dog Crate-trained?
No
Yes
Is your dog Socialized?
Does your dog know any Basic Commands?
Where does your dog sleep?
Do they have any possessive behaviors (growling / bitting) ?
Any history of aggression?
E. Goals
What are the goals you’d want to achieve through rehab with Ubera Rehabilitation?
Signature
Date
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Month
-
Day
Year
Date
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