Client Intake Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you a permanent or seasonal resident?
*
Permanent
Seasonal
Just visiting
Is this a gated community?
*
yes
no
Is this a dead end street?
*
yes
no
If yes, is there a cul du sac or a circular driveway to turn around?
yes
no
What day/s is your Trash, Recycle and Yard Waste picked up?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Phone Number
*
Please enter a valid phone number.
What type of phone is this?
*
Landline
Cell
Can you receive text messages?
*
yes
no
Email (required if you cannot receive text messages)
example@example.com
How did you hear about us?
*
Google
Facebook
Referral
Saw our vehicle
Other
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Pet Name
*
Pet Breed
*
Please Select
Australian Shepherd (up to 30 lbs.
Australian Terrier
Beagle
Bichon
Biewer Terrier
Cairn Terrier
Cat, Hairless
Cat, Longhair
Cat, Shorthair
Cavalier
Chihuahua, Longhair
Chihuahua, Shorthair
Chinese Crested
Chinese Crested Powder Puff
Cockapoo
Cocker Spaniel
Corgi
Dachshund, Longhair
Dachshund, Shorthair
Doodle (up to 15 lbs.)
Doodle (16 - 30 lbs.)
English Toy Spaniel
Field Spaniel
Havanese
Havapoo
Japanese Chin
Lakeland Terrier
Lhasa
Lhasapoo
Maltese
Mixed Breed, Longhair
Mixed Breed, Shorthair
Norfolk Terrier
Norwich Terrier
Papillon
Pekingese
Pekapoo
Pomeranian (up to 10 lbs.)
Pomeranian (over 10 lbs.)
Pomapoo
Poodle, Miniature
Poodle, Toy
Pug
Rat Terrier
Russell Terrier
Schnauzer, Miniature
Schnauzer, Standard
Schnoodle
Scottish Terrier
Sheltie
Shih Tzu
Shiapoo
Silky Terrier
Welsh Terrier
Westie
Westipoo
Wire Fox Terrier
Yorkshire Terrier
Yorkipoo
Cats are listed as Cat, Hairless; Cat, Longhair; Cat, Shorthair
If Breed is not listed above please type in breed here.
Pet Sex
*
Female Intact
Male Intact
Female Spayed
Male Neutered
Pet Age
*
Pet Weight
*
Rabies Expiration Date
*
-
Month
-
Day
Year
Date
Veterinarian
*
Does your pet need a Bath, Brushout or Haircut?
*
Haircut, includes bath service
Bath, includes nails cut and ears cleaned
Brush-out with no bath, includes nails cut and ears cleaned
How often do you want your pet groomed?
every 2 weeks
every 4 weeks
every 8 weeks
not sure
Has this pet been groomed before?
*
yes
no
I'm not sure
Does this pet have any health issues?
*
yes
no
If yes, please explain.
Is this pet nervous about strangers?
*
yes
no
Is this pet difficult to handle? (ie: bites, anxious, fights, doesn't like nails done)
*
yes
no
maybe
Would you like to add another pet?
*
Yes
No
Back
Next
Pet Name
*
Pet Breed
*
Please Select
Australian Shepherd (up to 30 lbs.
Australian Terrier
Beagle
Bichon
Biewer Terrier
Cairn Terrier
Cavalier
Chihuahua, Longhair
Chihuahua, Shorthair
Chinese Crested
Chinese Crested Powder Puff
Cockapoo
Cocker Spaniel
Corgi
Dachshund, Longhair
Dachshund, Shorthair
Doodle (up to 15 lbs.)
Doodle (16 - 30 lbs.)
English Toy Spaniel
Field Spaniel
Havanese
Havapoo
Japanese Chin
Lakeland Terrier
Lhasa
Lhasapoo
Maltese
Mixed Breed, Longhair
Mixed Breed, Shorthair
Norfolk Terrier
Norwich Terrier
Papillon
Pekingese
Pekapoo
Pomeranian (up to 10 lbs.)
Pomeranian (over 10 lbs.)
Pomapoo
Poodle, Miniature
Poodle, Toy
Pug
Rat Terrier
Russell Terrier
Schnauzer, Miniature
Schnauzer, Standard
Schnoodle
Scottish Terrier
Sheltie
Shih Tzu
Shiapoo
Silky Terrier
Welsh Terrier
Westie
Westipoo
Wire Fox Terrier
Yorkshire Terrier
Yorkipoo
If Breed is not listed above please type in breed here.
Pet Sex
*
Female Intact
Male Intact
Female Spayed
Male Neutered
Pet Age
*
Pet Weight
*
Rabies Expiration Date
*
-
Month
-
Day
Year
Date
Veterinarian (leave blank if same as above)
Does your pet need a haircut or just a bath?
*
Haircut, includes bath
Bath
How often do you want your pet groomed?
every 2 weeks
every 4 weeks
every 8 weeks
not sure
Has this pet been groomed before?
*
yes
no
I'm not sure
Does this pet have any health issues?
*
yes
no
If yes, please explain.
Is this pet nervous about strangers?
*
yes
no
Is this pet difficult to handle? (ie: bites, anxious, fights, doesn't like nails done)
*
yes
no
maybe
Would you like to add another pet?
*
Yes
No
Back
Continue
Continue
Next
Pet Name
*
Pet Breed
*
Please Select
Australian Shepherd (up to 30 lbs.
Australian Terrier
Beagle
Bichon
Biewer Terrier
Cairn Terrier
Cavalier
Chihuahua, Longhair
Chihuahua, Shorthair
Chinese Crested
Chinese Crested Powder Puff
Cockapoo
Cocker Spaniel
Corgi
Dachshund, Longhair
Dachshund, Shorthair
Doodle (up to 15 lbs.)
Doodle (16 - 30 lbs.)
English Toy Spaniel
Field Spaniel
Havanese
Havapoo
Japanese Chin
Lakeland Terrier
Lhasa
Lhasapoo
Maltese
Mixed Breed, Longhair
Mixed Breed, Shorthair
Norfolk Terrier
Norwich Terrier
Papillon
Pekingese
Pekapoo
Pomeranian (up to 10 lbs.)
Pomeranian (over 10 lbs.)
Pomapoo
Poodle, Miniature
Poodle, Toy
Pug
Rat Terrier
Russell Terrier
Schnauzer, Miniature
Schnauzer, Standard
Schnoodle
Scottish Terrier
Sheltie
Shih Tzu
Shiapoo
Silky Terrier
Welsh Terrier
Westie
Westipoo
Wire Fox Terrier
Yorkshire Terrier
Yorkipoo
If Breed is not listed above please type in breed here.
Pet Sex
*
Female Intact
Male Intact
Female Spayed
Male Neutered
Pet Age
*
Pet Weight
*
Rabies Expiration Date
*
-
Month
-
Day
Year
Date
Veterinarian (leave blank if same as above)
Does your pet need a haircut or just a bath?
*
Haircut, includes bath
Bath
How often do you want your pet groomed?
every 2 weeks
every 4 weeks
every 8 weeks
not sure
Has this pet been groomed before?
*
yes
no
I'm not sure
Does this pet have any health issues?
*
yes
no
If yes, please explain.
Is this pet nervous about strangers?
*
yes
no
Is this pet difficult to handle? (ie: bites, anxious, fights, doesn't like nails done)
*
yes
no
maybe
Would you like to add another pet?
*
Yes
No
Back
Next
Pet Name
*
Pet Species
*
Please Select
Dog
Cat
Pet Breed
*
If Breed is not listed above please type in breed here.
Pet Sex
*
Female Intact
Male Intact
Female Spayed
Male Neutered
Pet Age
*
Pet Weight
*
Rabies Expiration Date
*
-
Month
-
Day
Year
Date
Veterinarian (leave blank if same as above)
Does your pet need a haircut or just a bath?
*
Haircut, includes bath
Bath
How often do you want your pet groomed?
every 2 weeks
every 4 weeks
every 8 weeks
not sure
Has this pet been groomed before?
*
yes
no
I'm not sure
Does this pet have any health issues?
*
yes
no
If yes, please explain.
Is this pet nervous about strangers?
*
yes
no
Is this pet difficult to handle? (ie: bites, anxious, fights, doesn't like nails done)
*
yes
no
maybe
Would you like to add another pet?
*
Yes
No
Back
Next
Signature
*
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