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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