Initial Application Form
This form should be completed by the primary owner who is 18 years old or over and spends the most time with the dog. If the form is for a family dog, then please discuss the form together and any disagreements for this to be indicated on the form.
Contact Information
Title
*
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Date Form Completed
*
-
Day
-
Month
Year
Date
Is Your Dog Insured?
*
Yes
No
Insurance Renewal Date
-
Day
-
Month
Year
Date
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Information On Your Dog
Dog's Name
*
Age Of Your Dog Currently
*
Years
Months
What Age Did You Obtain Your Dog?
*
Years
Months
Dog's Breed
*
Pedigree
Single Cross (two different breeds)
Multiple Cross (more than two breeds)
Dog's Breed
*
Please Provide Details
*
Sex and Neuter Status
*
Male - Entire
Male - Neutered/Chemically Castrated
Female - Entire
Female - Neutered
Is the dog on any current medications/supplements
*
Yes
No
If Yes, Please Name Them and Dosages
Has your pet been on medication for behaviour in the past?
*
Yes
No
If Yes, Please Name Them and Dosages
Known Current Medical History
*
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Veterinary Practice Information
Practice Name
*
Vet Name
Practice Contact Number
*
(Your Veterinary Practice's Contact Number)
Practice Email Address
*
example@example.com
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Dog Behaviour Consultation
Please describe the nature of the behaviour that is causing concern, including how it is impacting you.
*
What do you hope to achieve with our support?
*
In cases of aggression, has the dog bitten?
*
Yes
No
If so, please describe the nature of the bite, including who was bitten, bite location, any warning signs, and the type of bite (deep, superficial, didn't puncture the skin)
Submit
Should be Empty: