Intake Form

1
Name* This field is required.
First Name
Last Name
2
Email
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Do you smoke in your home?
YESNO
6
Dogs Name/s
7
Dog Age/s
8
Dog Breed/s
9
Breed Size/s (you may select multiple if you have multiple dogs)
Please Select
Small 0-20 lbs
Medium 20-45 lbs
Large 45-85 lbs
X large 85+ lbs
10
Dog Gender
Please Select
Please Select
Female
Male
11
Spayed or Neutered?
Please Select
Spayed
Neutered
None
12
Does your dog frequently get matts or knots or does it currently have any? Please remember when a dog is excessively matted the best solution is for them to be shaved as matts are extremely painful.
YESNO
13
Has your dog ever bitten you or anyone else?
YESNO
14
Are there any health concerns that I should pay attention for or any issues they have had previously? * This field is required.Please be specific. I want to make sure I'm giving your pet the best experience possible.
Huge
Large
Normal
Small
Ok
Ok
15
Does your dog handle grooming well? If not please elaborate.
16
How would you describe your dogs personality?You may select multiple.
Shy
Scared
Compliant
Friendly
Excited
Aggressive
17
Rabies vaccine expiration/s* This field is required.
18
Vaccine records (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
19
Picture of Dog/s (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
20
Vet Name * This field is required.
21
Vet Phone Number * This field is required.
Please enter a valid phone number.
22
Emergency Contact
First Name
Last Name
23
Emergency Contact Phone Number
Please enter a valid phone number.
24
Terms and Conditions* This field is required.
25
Kindly provide your signature below to indicate your agreement with the above grooming waiver.* This field is required.
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