New Dog Intake Form

New Dog Intake Form
- Owner’s Name
  
  First NameLast Name
- Owner’s Email
  example@example.com
- Owner’s Home Address (where the dog primarily resides)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Owner’s Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Alternate/Emergency Contact Name
  
  First NameLast Name
- Emergency Contact Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Dog’s Regular Veterinarian
  
  Veterinarian's Name
  
  Practice
  
  CityState / Province
  
  Postal / Zip Code
- Dog’s Regular Veterinarian's Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Dog’s Name
- Dog’s Breed
- Dog’s Sex
- Is the dog sterilized (neutered or spayed)
- Dog’s Date of Birth
  
  MonthDayYear
  Date
- Date of Dog’s Most Recent Fecal Float
  
  MonthDayYear
  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
- 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?
- If “Yes” please be specific:
- Does your dog have a sensitive stomach?
- If “Yes” please be specific:
- Does your dog have allergies or any medical conditions?
- If “Yes” please be specific:
- Is your dog crate trained?
- If”Yes” please be specific on when and how, if “No” please state why:
- Does your dog chew or ingest bedding?
- If “Yes” please be specific:
- Does your dog chew or ingest toys?
- If yes, please be specific:
- Is your dog allowed on furniture?
- If “Yes” please be specific:
- Has your dog ever shown signs of aggression towards dogs? (Barking, lunging, growling, biting etc.)
- 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.)
- Please explain in detail and if a bite occurred, anyone was anyone injured, broken skin etc.
- Should be Empty: