HIGH DESERT CANINE WELLNESS: CUSTOM INTAKE FORM

HIGH DESERT CANINE WELLNESS

CANINE INTAKE FORM
Name

First NameLast 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.
Email
example@example.com
Dog Name
Dog Date of Birth
Dog Age
What age was you dog when he/she came to live with you?
Breed
Dog Weight (approximate if unknown)
Dog's Weight is considered:
Gender
Reproductive Status:
If Spayed:
If neutered:
Age at time of spay/neuter
Please list any behavioral/emotional/physical problems your dog exhibited after spay/neuter.
Has your dog ever been pregnant?
How many litters?
Please check all vaccines your dog has received (please note that some vaccines such as DHLPP contains 5 vaccines in one: Distemper, Adenovirus, Leptospirosis, Parainfluenza and Parvovirus-check each individual vaccine)

Other
Date of last vaccination
Is your dog currently on any medications or supplements?
List all medications or supplements
Has your dog ever had surgery?
List reason(s) for surgery
Please list all PREVIOUS medications and supplements (including anesthesia) as well as any flea/tick/heartworm prevention.
Current diet:
Explain other
Brand and daily amount
What types of chemicals is your dog exposed to?

Other
Please select any health conditions your dog is currently exhibiting OR has had in the past :

Other
Please select any behavioral problems your dog exhibits:

Other
Please describe your dog's lifestyle: What a typical day looks like for your dog such as: How much outdoor time he/she gets, how much exercise, how much training, whether your dog has a fenced in yard, what size yard, other animals in the home, where your dog sleeps, your dog's favorite toys, activities, how much time is spent home alone and any other relevant information.
What are your concerns regarding your dog's health?
What are your goals for your dog's health?
SUMMARY: Please check each box that applies to your dog:

Other
On a scale of 1-10, how would you rate your knowledge of natural rearing principles, including raw feeding. 10 being extensive knowledge.
Should be Empty: