Zoomiez Mobile Dog Gym Intake Form
Welcome! Please complete this form to help us get to know you and your dog for a fun and safe Zoomiez experience.
Owner Contact Details
Client Name
*
First Name
Last Name
Client Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client Email Address
*
example@example.com
Client Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
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Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
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The Bahamas
Bahrain
Bangladesh
Barbados
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Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
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Guinea
Guinea-Bissau
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Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Dog Profile
Dog Name
*
Dog Breed
*
Dog Age (years)
*
Dog Weight (lbs)
Upload a picture of your dog
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Health and Vet Info
Is the dog up to date on vaccinations?
*
Please Select
Yes
No
Unsure
Known heart conditions (Type No if none)
*
Known joint issues (Type No if none)
*
Known respiratory problems (No if none)
*
Preferred Veterinarian Name
Preferred Veterinarian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Behavior and Temperament
Is the dog treat-motivated or toy-motivated?
*
Treat-motivated
Toy-motivated
Both
Other
How does the dog react to stranger's?
Friendly
Cautious
Fearful
Aggressive
Indifferent
Any history of leash reactivity?
Yes
No
Any history of aggression?
Yes
No
Activity/Fitness Goals and Service Selection
Please describe your dog's activity level.
Low
Moderate
High
Very High
Scheduling Preferences and Location Details
Please share your preferred scheduling times and day(s) of the week. Any specifc location details I need to know?
Policies, Liability Waiver, Emergency Treatment Authorization, and Media Release
Liability Waiver
1. Nature of Service Zoomiez provides physical exercise and cardiovascular conditioning for dogs via a non-motorized slatmill. I understand that Zoomiez is a fitness provider and not a licensed dog trainer or veterinary behaviorist. Sessions are designed for physical fulfillment and are not intended to treat or modify behavioral issues such as aggression, separation anxiety, or reactivity. 2. Health & Veterinary Clearance I warrant that my dog is in good physical health and has been explicitly cleared by a licensed veterinarian for high-intensity cardiovascular exercise. I have disclosed all known medical history, including but not limited to heart conditions, respiratory issues, joint dysplasia, or recent surgeries. 3. Assumption of Risk I acknowledge that high-intensity athletic activity carries inherent risks, including muscle strain, fatigue, or minor abrasions. I understand that transitioning a dog to a mobile environment involves unpredictable variables. I assume all risks associated with my dog’s participation in these sessions and agree that Zoomiez is not liable for injuries resulting from the dog’s natural physical responses or pre-existing conditions. 4. Handler Authority & Safety Zoomiez maintains “Stop-Work Authority.” If a dog shows signs of overheating, extreme stress, or physical distress, the session will be terminated immediately. No dog will be forced to exercise against its will. I understand that if my dog is too apprehensive to enter the van, the session may pivot to a “Confidence/Scent & Sight” session at the handler's discretion. 5. Handler Disclosure I acknowledge that the operator of Zoomiez is a Canine Fitness Professional and not a certified dog trainer. I understand that no behavioral training is being provided during these sessions, and Zoomiez makes no guarantees regarding the improvement of the dog’s behavior outside of physical tiredness. 6. Emergency Care In the event of a medical emergency, Zoomiez will attempt to contact the Owner and the preferred Veterinarian listed on the intake form. If neither is reachable, Zoomiez is authorized to seek emergency veterinary care at the Owner’s expense. 7. Media Release I grant Zoomiez permission to record and use photos or videos of my dog for marketing and social media purposes, unless otherwise requested in writing. 8. Indemnification I agree to indemnify and hold harmless Zoomiez and its operators from any and all claims, damages, or expenses arising from my dog’s participation, including any damage caused by my dog to the Zoomiez van or equipment.
I give permission for my dog to be photographed or video recorded for social media marketing.
*
I consent
I do not consent
Signature
*
Date
*
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Month
-
Day
Year
Date
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