The Canine Clubhaus Customer Intake
Owner Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Were you referred by someone?
Yes
No
Who were you referred by?
Occupation
Dog Information
Dog's Name
Breed
Age
Spay / Neutered?
Yes
No
Veterinarian
Medical Problems/meds/allergies
Brand of Dog Food
How often fed?
How is your dog rewarded?
Other treats & how often?
Where was dog obtained?
How is your dog corrected?
How does your dog do with meeting new people? (calm, jumping, hides, growls)
How long have you had the dog?
Where is your dog kept when the primary person is gone?
Is the dog housebroken?
Yes
No
Is the dog crate trained?
Yes
No
Exercise type / Frequency?
Equipment used on walks
Where does your dog sleep?
% time kept inside / outside
Has your dog had any previous training?
Reason for consultation?
Household Information
List other persons in the household
List other pets in the household
Who interacts with the dog on a daily basis?
Has your dog ever bitten or injured a person or an animal?
Yes
No
What happened?
Form Info
Method of Payment
Cash/Check (due on 1st session)
Paypal (send payment to manuela@thecanineclubhaus.com )
Credit Card (pay now)
Which Service Plan?
prev
next
( X )
1 Session (in-home)
$
220.00
3 Sessions (in-home)
$
650.00
6 Sessions (in-home)
$
1,300.00
Total
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
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