New Client Intake Form

New Client Intake Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Do you or your spouse work in Law Enforcement, Fire Services, or are you currently active military? If yes, please tell us what department/ town/ branch.
Emergency Contact (If we are unable to reach you)
Name

First NameLast Name
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?
Dog's Name
Male or Female
Neutered/Spayed?
Date of Birth

MonthDayYear
Date
Approximate age
Breed:
Color/ Coat Description
Did your dog come from a breeder or a rescue (Name of Breeder or Rescue)?
Have you ever owned a dog before?
If you have not had him/her from puppyhood, what do you know of the dogs prior history?
Other animals in the household? (Species/Breed/Age)
Has your dog ever attended a doggy daycare?
If you answered yes, please tell us the name and location of the daycare and why you are choosing to leave them
Please describe your dogs overall temperament and how they interact with other dogs
Has your dog ever bitten a person or another dog?
Are there any particular types of people or dogs that your dog seems to fear or dislike? Please explain.
Has your dog ever tried to escape from home/backyard/vet/etc?
Does your dog jump fences?
Is your dog trained to use ,and comfortable using, a crate?
Has your dog ever boarded at a facility?
Will your dog share a water bowl with other dogs?
If your dog has any allergies or sensitivites, please list them here
Does your dog have any disabilities or health issues? Please describe
Is your dog on Flea and Tick preventative? Please describe:
Is your dog currently licensed in the town of your residence? (Required for attendance, per MGL Chapter 140 Sec. 137)
All dogs attending Waggerz MUST be up to date on the following vaccinations with no exceptions: Rabies, Distemper/Parvo combination, and Bordatella (Kennel Cough). Please upload a copy of current vaccinations and current dog license here, if you are unable to upload, please email license paperwork and vaccine due dates to waggerzinfo@gmail.com

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Veterinary Practice Information
Practice Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
By signing, I certify that the above information is complete and correct
Should be Empty:

New Client Intake Form

Emergency Contact (If we are unable to reach you)

Veterinary Practice Information