Intake Form
Today's Date
/
Month
/
Day
Year
Date
Owner/Agent Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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How many other animals in your family? How many adults and children? (include ages)
1st Dogs Name
Breed
DOB or estimation
-
Month
-
Day
Year
Date
Where did purchase or adopt your dog?
Male or Female
Male - Neutered
Male - Not neutered
Female - Spayed
Female - Not spayed
Aggression or Reactivity
People
Kids
Dogs
Food
Other
Has dog ever bitten or injured a person or animal? If yes, describe:
Prior Training? If so, describe (include cues he/she knows and methods used):
What are your goals for you and your dog? What types of activities interest you?
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Multiple Dogs
2ⁿᵈ Dogs Name
Breed
DOB or estimation
-
Month
-
Day
Year
Date
Where did purchase or adopt your dog?
Male or Female
Male - Neutered
Male - Not neutered
Female - Spayed
Female - Not spayed
Aggression or Reactivity
People
Kids
Dogs
Food
Other
Has dog ever bitten or injured a person or animal? If yes, describe:
Prior Training? If so, describe (include cues he/she knows and methods used):
What are your goals for you and your dog? What types of activities interest you?
How much food does your dog get, how many times a day, and where do they eat?
Daily routine and exercise:
3rd Dogs Name
Breed
DOB or estimation
-
Month
-
Day
Year
Date
Where did purchase or adopt your dog?
Male or Female
Male - Neutered
Male - Not neutered
Female - Spayed
Female - Not spayed
Aggression or Reactivity
People
Kids
Dogs
Food
Other
Has dog ever bitten or injured a person or animal? If yes, describe:
Prior Training? If so, describe (include cues he/she knows and methods used):
What are your goals for you and your dog? What types of activities interest you?
How much food does your dog get, how many times a day, and where do they eat?
Daily routine and exercise:
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Referred by
Veterinarian Contact
Format: (000) 000-0000.
By signing, owner/agent of listed dog(s) assure all information is true.
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Should be Empty: