Canine Behavioral Consult Intake Form

Canine Behavioral Consult Intake Form

Dr. Anna Mukhina
Thank you for your interest in our Behavioral Medicine Department. The information you provide will help us understand your pet’s medical and behavioral history, lifestyle, and goals for the consultation.

Please complete a separate form for each pet you would like Dr. Mukhina to evaluate. After submitting this form, you may complete additional forms for other pets in your household, if needed.

Medical records are required for review before an appointment can be scheduled. Once we receive your completed intake form and records, our scheduling team will review the information and contact you with available appointment options.

Please allow up to 5 business days for a response. If you have not heard from us after 5 business days, please feel free to reach out to follow up on the status of your request.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Have you been to Mount Laurel Animal Hospital previously?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has your address changed?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to add another contact to your account?
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Pet's Information
Pet's Name:
Has your pet been to Mount Laurel Animal Hospital previously?
Pet's Age (or date of birth, if known):
Sex & Alteration Status:
Breed:
Coat/Fur Color:
Primary Vet Information

If your pet is seen elsewhere (other than MLAH) for primary care, please have your pet's veterinary records emailed to appointments.behavior@mlahvet.com or faxed Attn: Behavioral Medicine to (856) 231-8393

Your pet's medical records can also be uploaded below.
Upload Medical Records

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Is your pet seen elsewhere for primary care?
Veterinary Hospital/Clinic Name:
Veterinarian's Name:
Veterinarian's Phone #:
Veterinarian's Email Address:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason For Visit
Does your pet's behavior involve another pet in the household?

Briefly describe your top 2 - 3 concerns regarding your pet's behavior. These concerns will be the primary focus of your initial appointment with Dr. Mukhina:

Rows	Description of behavior	How often does this behavior occur?	What usually triggers this behavior?
Concern #1
Concern #2
Concern #3

When did your pet's behavioral concerns start?
What are your specific goals for this appointent?
Pet History
When did you acquire your pet (approximate date)?
How old was your pet when you first acquired them?
If unknown, please make your best guess.
Where did you acquire your pet?
e.g., breeder, friend, rescue, pet store, etc.
Do you have information about your pet's behavior as a puppy?
If yes, please describe:
Did you meet your dog's parents or do you have any information about littermates?
If yes, please describe:

Household And Environment

Please list all of the animals living in your pet's household. For each animal, describe their relationship with the pet being evaluated (e.g., friendly, playful, fearful, aggressive, avoids, neutral, etc.)

Rows	Name	Species/Breed	Age	Sex	Spayed/Neutered?	Date Acquired	Age When Acquired	Relationship with Pet Being Evaluated
Pet #1
Pet #2
Pet #3
Pet #4
Pet #5
Pet #6
Pet #7
Pet #8

What type of area do you live in?
e.g., urban, suburban, rural
What type of home do you live in?
e.g., apartment, rowhome, house, etc.
Do you have a fenced-in yard?
If yes, please indicate the height and type of fencing:
e.g., 4 foot, 6 foot, privacy, chain link, electric fencing

Please list all of the people living in your household, including yourself:

Rows	Name	Relationship to you	Age	Gender identity (optional)	Quality of relationship with the pet	Does this person have any food allergies? Please list.
Yourself
Person #2
Person #3
Person #4
Person #5
Person #6
Person #7
Person #8

Medical History
Please list any current or past medical conditions or health concerns:
If there are no medical conditions or health concerns, type None.
Does your pet have any food allergies or diet restrictions?
If yes, please describe:
e.g., list any prescription diet or specific food restrictions
Is your pet currently receiving year-round heartworm and flea/tick prevention?
If yes, please list the name(s) of the preventative(s) your pet is receiving:

Please list all medication(s) and supplements(s) your pet is currently taking, including any behavioral medication:

Rows	Medication name	Strength (mg, mg/ml)	How much is given per dose (tablet, liquid volume)	How often? (every 8, 12, 24 hours, or as needed)
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Medication #9
Medication #10

Please list any behavior medications and supplements your pet has used previously:
If there are none, type N/A or None.
Please provide the date of your pet's most recent rabies vaccine:
If your pet has never had a rabies vaccine, type N/A
Please note: If your pet is not current on their rabies vaccination, Dr. Mukhina will administer a rabies vaccination during the appointment. This ensures your pet meets the required rabies vaccination standard. If you have documentation of a previous rabies vaccination, please provide it before your appointment. Otherwise, the vaccine will be recorded as a 1 year rabies vaccination in accordance with state guidelines.
Training And Behavior History
Has your pet been seen previously by a veterinary behaviorist?
If yes, please provide us with the veterinary behaviorist's information:
If your pet was seen by a behaviorist outside of Mount Laurel Animal Hospital, please provide us with records, if you haven't already done so:

Or email to: appointments.behavior@mlahvet.com
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What types of training has your pet participated in? This can include professional training as well as self taught training with the help of books, videos, etc:
e.g., group classes, private lessons, training boot camps
What types of training methods, enrichment, or equipment have you utilized?
e.g., treats, food puzzles, clicker training, flat collar, prong collar, electric collar, verbal corrections, etc
Please describe your pet's behavior during veterinary visits and exams:
eg., fearful, anxious, aggressive, etc.
If you have videos or photos that demonstrate your pet's concerning behaviors, please attach them here. Do not attempt to obtain a photo or video that would expose you or your pet to unsafe conditions:

Or email to appointments.behavior@mlahvet.com Please limit to 5 videos/photos.
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Does your pet have a history of biting people or other other pets?

Have you ever considered rehoming or humane euthanasia due to behavior-related concerns? We understand these decisions can be incredibly difficult and there is no judgement in your response. Your answer helps us better understand your family's needs and goals.
Please select every day you are available for an appointment:
Will anyone attending the consultation have difficulty using stairs?
Thank you for taking the time to complete this intake form. We understand that living with behavioral challenges can be stressful, and we appreciate your openness in sharing your experiences. Your responses will help us provide the most individualized recommendations and support for you and your pet.
If you would like to submit a form for another pet in your household, simply click Submit below. After your submission is complete, you'll have the option to fill out a form for each additional pet. Please note: If multiple pets attend the appointment, each pet must have a separate handler.
Should be Empty:

Rows	Date	Brief description	Was skin broken?	Was medical attention needed?	Reported to health authorities?	Was legal action taken?
Incident #1
Incident #2
Incident #3
Incident #4

Canine Behavioral Consult Intake Form

Your Pet's Information

Reason For Visit

Pet History

Household And Environment

Medical History

Training And Behavior History