New Client Intake Form

New Client Intake Form

Please complete the following form before your first appointment.
Client's Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Contact Email Address
example@example.com
Additional Pet Parent

First NameLast Name
Additional Pet Parent's Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Pet Parent Email Address
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dog's Information

If you have multiple dog's, please complete a separate intake form for each dog.
Dog's First Name
Dog's Birthday

MonthDayYear
Date
Dog's Breed(s)
Please include primary & secondary breed(s), if applicable
Dog's Sex
Dog's Neuter Status
Veterinary Practice
Please upload your dog's vaccine record

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Please upload a photo of your dog

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Physical & Behavioral Health Information

The following information is intended to provide general background information about your dog's health and behavior before your first appointment. Any non-applicable questions can be left blank.
What does your dog eat? Please provide information about your dog's meals (brand, protein, amount, frequency). Please also include information for treats, chews, and supplements, if applicable.
Does your dog have any dietary allergies?
Include symptoms of allergy
What medications does your dog take? Please list all medications, dosage, & schedule. INCLUDE flea/tick/HW preventatives.
Example: Reconcile (16 mg; daily) started 1/1/2025 for anxiety
Do any of the following apply to your dog's behavior?
Does your dog have a bite history?
Please explain behavioral concerns and relevant significant incidents in more detail:

Scheduling, Payment, & Submission
What services are you potentially interested in?
How did you hear about us?
Current services, pricing, and the scheduling portal are located at https://villagecanine.as.me/

Invoices will be created at the time of scheduling. Payment transactions are initiated after completion the scheduled service. Vacation Care requires a non-refundable deposit of 50% of the estimate at the time of scheduling.

Submission of this form agrees to Village Canine's terms and conditions.
Signature
Should be Empty:

Dog's Information