Dog History Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Phone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Where did you hear about us?

Your dog's name

How old is your dog?

What breed is your dog?

What age did you get your dog and where from?

What previous experience do you have with dogs?

Please list other household pets, names, species, ages, gender (neutered or not) and relationship with your dog

Do you give us consent to contact your Veterinary Practice for referral and access to all veterinary records for the above named pet? Please note, that we only work on veterinary referral which includes review of veterinary notes for your pet.

Which Veterinary Practice is your dog registered at?

Address for Veterinary Practice where your pet is registered

Is your dog insured?

If Yes, and your insurance covers for behaviour problems and you would like to do a direct claim*, please let us know the following: Insurance Company / Policy number / Excess amount

* Please note that a Direct Claim is where you pay us your excess and we claim the rest of the fee back from your insurance company. By filling in the details above, you agree to raising the claim with your insurance company and/or give us permission to contact your insurance company to make a direct claim on your behalf and also agree to paying us the balance within a set time frame should they decline the claim for any reason.

About the problem behaviour. What are the main areas of your pets behaviour which you wish to focus on during the consultation?

When did you first notice this/these problem behaviours?

How long has the problem behaviour been present?

How often do these/this problem occur? E.g. multiple time a day, weekly, monthly

Where does the problem behaviour occur?

With whom does the problem behaviour occur?

Is the problem getting (please select from below)

Have any actions been taken so far since noticing this behaviour? If so, please detail below, also noting the outcome of the action taken.

Is your pet currently on any medications or supplements etc. (such as dietary supplements or herbal products)? If yes, please list name and dosage.

Please list names and ages of other family members who live at home and how you would describe the relationship of each family member with your dog:

Does your dog treat all members of the household the same?

What are the feelings of each family member in relation to this/these problem behaviours?

How would you describe your dog’s personality?

How would your dog know they have done well?

How do you correct your dog when s/he misbehaves?

Please describe a typical 24 hours in your pets life

Do you walk your dog? If so, on average for how long and what amount is on lead/off lead/mix of on/off lead?

What is your dogs reaction to strangers when out (e.g. unknown males, females, children, known and unknown dogs)?

Is there any sort of aggression in the following circumstances? (growling, snarling (showing teeth), lunging, nipping, biting). Please select all which apply.

Has your dog ever bitten or attacked anyone? If yes, please provide further details.

What are the essential changes you need to be able to continue to live with your dog?

Under what circumstances would you consider euthanasia?

Please give any other information you think relevant to the case.

Consent for using Case material for markting and educational use

We sometimes use case material to support professional education, supervision, mentoring and training. This may include helping students, veterinary professionals and behaviour professionals develop their knowledge and skills.

Your decision is entirely optional. Saying “No” will not affect the service you receive from Pet Behaviour Company.

Please be assured that we will remove your name, contact details and other obvious identifying details wherever possible. However, some information, photographs, videos, audio recordings, home details or unusual case details may still make you, your household or your pet recognisable.

You can withdraw consent for future use at any time by contacting admin@petbc.co.uk. Withdrawal of consent will not affect any use that has already taken place before we received your request, but we will stop using the material for new purposes where we are able to do so.

1. Use of anonymised case details for marketing

Are you happy for Pet Behaviour Company to use anonymised details about your pet’s case for marketing, such as website content, social media posts, newsletters or promotional material?

We will not use your name, address, contact details or identifying photographs/videos for marketing unless we have separate written permission from you.

2. Permission to use anonymised written case material for professional education

Pet Behaviour Company sometimes uses anonymised written case material to support professional education, supervision, mentoring and case discussion. This helps veterinary professionals, clinical animal behaviourists, trainers, students and those working towards professional recognition to understand how behaviour assessments are made, how treatment plans are developed, and how clinical reasoning is applied in practice.

Use of anonymised written case history:

Are you happy to give permission for Pet Behaviour Company to use information from your pet’s case to create an anonymised written case history for professional education.
This may include relevant details about your pet’s behaviour, history, environment, veterinary background, assessment, treatment plan and progress.
You understand that Pet Behaviour Company will remove or change obvious identifying details, such as your name, contact details, address, precise location, veterinary practice name and other details that are not needed for educational discussion.
You understand that the anonymised written case history may be used in paid professional education, including online case discussion sessions, webinars, courses, mentoring or training resources.
You understand that these sessions may be attended by veterinary professionals, behaviour professionals, trainers, students and people working towards professional recognition in the animal training and behaviour field.
You understand that Pet Behaviour Company will take reasonable steps to reduce the risk of identification, but that very unusual case details may still carry some risk of recognition.
You understand that you can withdraw permission for future use by contacting admin@petbc.co.uk. Withdrawal will not affect any use that has already taken place before the request is received, but Pet Behaviour Company will stop using the material in future where reasonably possible.