The Canine Clubhaus Customer Intake

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?

1 Session (in-home) $ 160.00

3 Sessions (in-home) $ 500.00

6 Sessions (in-home) $ 1,000.00

Total $ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

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