New Dog Intake Form
Owner Info
Owner’s Name
*
First Name
Last Name
Owner’s Email
*
example@example.com
Owner’s Home Address (where the dog primarily resides)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner’s Phone Number
*
Please enter a valid phone number.
Alternate/Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Veterinarian Info
Dog’s Regular Veterinarian
*
Veterinarian's Name
Practice
City
State / Province
Postal / Zip Code
Dog’s Regular Veterinarian's Phone Number
*
Please enter a valid phone number.
Dog Info
Dog’s Name
*
Dog’s Breed
*
Dog’s Sex
*
Male
Female
Is the dog sterilized (neutered or spayed)
*
No
Yes
Dog’s Date of Birth
*
-
Month
-
Day
Year
Date
Date of Dog’s Most Recent Fecal Float
*
-
Month
-
Day
Year
Date
Fecal Float Result (your veterinarian should provide this). If you dont have it available, you may email it later.
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Result and Treatment (if any)
*
Example: Negative, or Positive for Hookworms, treated with Panacure
Dog is up to date on the following vaccinations: Rabies, Distemper, Adenovirus, Parvovirus, and Parainfluenza
*
Yes
No
Vaccine Record (your veterinarian should provide this). If you dont have it available, you may email it later.
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Please Explain
*
Dog’s Food
*
Be Specific, list brand and formula
Meals per day
*
How often does the dog get fed per day
Amount of Food per Meal
*
How much food (in cups) is given per individual meal
Supplements or Medications
*
Additional Feeding Notes
*
Is your dog a finicky eater?
*
Yes
No
If “Yes” please be specific:
*
Does your dog have a sensitive stomach?
*
Yes
No
If “Yes” please be specific:
*
Does your dog have allergies or any medical conditions?
*
Yes
No
If “Yes” please be specific:
*
Is your dog crate trained?
*
Yes
No
If”Yes” please be specific on when and how, if “No” please state why:
*
Does your dog chew or ingest bedding?
*
Chews
Ingests
No
If “Yes” please be specific:
*
Does your dog chew or ingest toys?
*
Chews
Ingests
No
If yes, please be specific:
*
Is your dog allowed on furniture?
*
Yes
No
If “Yes” please be specific:
*
Has your dog ever shown signs of aggression towards dogs? (Barking, lunging, growling, biting etc.)
*
Yes
No
Please explain in detail and if a bite occurred, anyone was anyone injured, broken skin etc.
*
Has your dog ever shown signs of aggression towards humans? (Barking, lunging, growling, biting etc.)
*
Yes
No
Please explain in detail and if a bite occurred, anyone was anyone injured, broken skin etc.
*
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