DOG BEHAVIOUR CONSULTATION APPLICATION

DOG BEHAVIOUR CONSULTATION APPLICATION
Please verify that you are human
Please take a moment to fill in this form before our first consultation and return it to me as soon as possible.

A consultation will take place at your home. Before this takes place, please record as much video as you can of your pet behaving both normally and engaged in the behaviour you are finding problematic. You can send this to me via email/Facebook Messenger/Dropbox/Whatsapp prior to the consultation. After the consultation, I will prepare a behaviour modification program for you and your pet/s.
Please secure your dog safely in a separate area for my arrival. I do NOT need to meet your pet on my arrival and reserve the right not to enter your property if this instruction has not been followed. Interactions will be strictly on my terms to avoid injury to all parties involved.
YOUR DETAILS

Note: All information shared below will be treated as confidential.
Name

First NameLast Name
Cell Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Directions
Please include directions or send a pin location on the day.
Alternate Contact (e.g. partner, roommate)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

VETERINARY DETAILS
Veterinary Practice Name
e.g. Blue Hills Veterinary Hospital
Veterinarian
e.g. Dr John Smith
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Reason for most recent visit
e.g. Vaccinations, lipoma removal
Date of most recent visit

YearMonthDay
Date of most recent vaccination

YearMonthDay
Does your dog have any chronic conditions?
e.g. allergies, arthritis
Is your dog on any chronic medication, including supplements (e.g. CalmEze/CBD oil).
e.g. Clomicalm, cortizone
What food does your dog mainly eat?
Royal Canin, Large Breed
Number of meals per day?
Has the diet changed recently? If so, how long ago and what was it previously?
e.g. Yes, 3 months, raw feeding
What extras/treats does your dog get and in what context?
e.g. training/midday nibbles/dessert/randomly etc.

What are your primary goals in changing your dog's behaviour?
I am a tutor for COAPE International. Would you be comfortable with a student attending the consultation in order to gain experience?
I, the undersigned, understand that no guarantee is given and I have been made aware, and understand that the successful modification of my pet's behaviour problem is dependent on my cooperation and adherence to the provided Behaviour Modification Plan.

Jessica Prinsloo will not be held liable for any damages that may occur during or as a result of the consultation.

I declare by signature that the information given in this interview is true and correct.
Client Signature
Date

YearMonthDay
Please feel free to contact me if you have any questions or concerns.

I look forward to working with you and your pet/s!
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YOUR DETAILS