Clone of Client Information Form

Client Information Form

To schedule a consultation, please fill out the form entirely. Please complete a separate form for each dog. Consultations will typically be scheduled for a date, 1-2 weeks after the form is submitted. Please answer the questions that follow as thoroughly as possible. All answers are confidential and will help me serve you better.
I will get back to you as quickly as possible with available time slots. Thanks very much!!
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Occupation
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
What is your availability? Please check all that apply:

Other
How did you hear about me?
Dog's Name
Dog's Date of Birth

MonthDayYear
If unsure, please write approximate date.
Weight (Kg)
Breed(s)
Where did you get your dog?
please list name of breeder or rescue organization if applicable
Photo of your dog:

Please upload a photo of your dog
Cancelof

Medical Information and History
Veterinarian's name (office name) and phone number:
Date and reason for last visit:
Date last vaccinated and vaccines administered:
Date of last blood test and abnormal findings if any:
Is your dog easily handled by vet staff?
Has your dog needed to be muzzled at the vet?
List any current health problems and medications:
If None, type None
List past health problems and treatments:
If None, type None
List detail any sensitivities or allergies including food and environmental:
If None, type None
Which flea and tick preventative do you use?
If None, type None
Which heartworm preventative do you use?
If None, type None
Is your dog spayed/neutered? If so, at what age?
If Intact, type No
Was your dog spayed/neutered for a behavioural or medical reason?

Diet and Elimination
What type of food do you feed (raw, home-cooked, kibble, wet)? Please include details about diet history if you have changed diets.
How often and what approximate times?
If you free-feed (leave food out all day), write free feed
How much do you feed your dog per day?
eg two cups of kibble or 1 lb of raw patties
Does your dog finish all food at meals?
If not, how long is food left out?
Does your dog receive other treats or chews? What are your dog's favourite treats?
How many times a day do you take your dog out to eliminate?

Client Information Form