Adult Proactive Intake Form
I can't wait to get to learn more about you and your dog. Thank you for placing your trust with Mirage & Marrow!
General Information
Please enter your Order #:
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This should be on your confirmation email
Have we worked together before? If so, please enter your original Order #.
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If you aren't sure what your ID is, please reach out to me via email.
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
Please enter a valid phone number.
How did you learn about Mirage & Marrow?
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Tell Me About Your Dog
There is no such thing as too much information. Please be detailed, where applicable.
Dog's Name
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Breed
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If a mixed breed, please provide information on genetic makeup to the best of your ability.
Coat Color
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Age
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Year : Months
Is the age entered above exact or an estimate?
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Please Select
Exact
Estimate
Gender?
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Intact Male
Intact Female
Neutered Male
Spayed Female
What is your dog's current weight (lbs)?
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What is your dog's body condition score?
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Use the Nestle Purina Bond Condition System Chart, link below
Nestle Purina Bond Condition System Chart
What is your pet's ideal weight (lbs)?
Leave blank if pet is at ideal weight.
Does your dog's vet comment about your dog's weight and/or have any concerns about it? If so, please explain.
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What is your dog's general stool quality?
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Use the Bristol Stool Chart, link below.
Bristol Stool Chart
How long has your dog been in your care?
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Which is describes your dog's activity level?
Please Select
Sedentary
Lightly Active
Moderately Active
Highly Active/Working
Please walk through your dog's weekly activities/exercise.
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Please be as detailed as possible.
For very high energy or sport dogs, does their level of activity differ between seasons/throughout the year? If yes, please describe.
Please be as detailed as possible.
Health Information
There is no such thing as too much information. Please be detailed, where applicable.
Does your dog have any health conditions? If yes, please describe, with the name of the condition, time of diagnosis and any other information that you find relevant.
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Is your dog taking any medications? If yes, please list.
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Describe the condition of your dog's coat, skin, teeth, breath and ears.
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Does your dog have any food allergies or intolerances? If yes, please name the food, their symptoms and when the allergy/intolerance manifested.
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Does your dog have feeding restrictions? (ex: low fat diet) If yes, please describe below.
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Please describe your dog's bowel movements (frequency, gland issues, straining, and so on).
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How often does your dog have loose stool, nausea, or experience vomiting?
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Current Diet and Diet History
There is no such thing as too much information. Please be detailed, where applicable.
Describe what you are currently feeding daily. Please be as specific as possible and include daily calorie intake. If the current diet is relatively new, please describe previous diet(s) as well and general diet history.
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Example of level of detail: for the week: 4 lbs of 80/20 Ground Beef, raw, 4 lbs of Boneless and Skinless Chicken Thighs, raw, 0.5 lbs of Boiled Carrots, 0.5 lbs Roasted Squash ... If commercial, please list brand and full product name. A link would be helpful as well.
How much food do you feed your dog in a day?
If you have a food scale, please weight their food (oz, g or lbs) This is preferred over volume (cups).
How long has your dog been on their current diet?
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How many meals do you feed in a day?
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1
2
3
Free-Feeding
Other
If you chose "Other" above, please describe the how often you feed your dog.
Does your dog take any supplements? This may include items like vitamins, minerals, probiotics and so on. If yes, please list them below, along with the frequency of use and amount
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Please be specific and include brands and specific product names. Example: Solgar Vitamin E (IU 100) - 1x a day
Describe your dog's overall appetite.
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For example: are they picky? Do they leave food? Do they scarf food down?
Describe any extra food intake, like treats, chews and toppers.
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Please provide as much detail as you can. Brands, flavors, frequency of feeding, and so on.
Are there foods your dog does not like? If so, please list them. Are they open to new foods?
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If your dog is picky will they accept items they don't prefer if they're hidden? If so, how do you hide them?
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Dog's Environment
Where does your dog spend a majority of their day/week? (ie: inside, outside, doggy day care)
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Are there other pets in the house? If so, how many and what species? How is your dog's relationship with them?
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Are there any recent life changes? (ie: new baby, just moved, new pet). If yes, please describe.
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How much exposure does your dog have to chemicals? (ie: detergents, pesticide spray, herbicide spray)
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Your Preferences
If you are comfortable answering, how much money do you spend monthly on your dog's food?
Are you comfortable with how much you pay for your dog's food?
I prefer to formulate using NRC nutrient guidelines. Are you comfortable using this guideline for recipe formulation, if not please explain why.
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How would you like to feed your dog?
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100% home-prepared
75% home-prepared, 25% commercial
50% home-prepared, 50% commercial
25% home-prepared, 75% commercial
Mostly commercial, with toppers
If your preference is for your dog's diet to be mostly commercial, roughly what percentage of their food would you like to be home-prepared?
Do you prefer a majority of ingredients to be raw or cooked?
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Raw
Cooked
No Preference
If you have preferences, list ingredients or brands of foods or supplements that you would like included in the recipe. Please understand that I may not be able to use all of them, but I will do my best.
Are there ingredients or types of food and/or supplements that you would like to avoid?
Has your dog eaten raw bones before?
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Yes
No
Would you like to feed raw meaty bones? If so, do you prefer whole bones or ground only.
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Yes, whole only
Yes, ground only
Yes, either ground or whole is fine
No, use supplements only
How often do you prefer to prep your meals?
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Once a week
Every 2 weeks
Every 4 weeks
Other
If you chose "Other" above, please explain how often you would like to prep meals for your dog.
Please list any tools at your disposal that may be used for prepping meals. (ex: food scale, food processor, blender, meat grinder, stovetop, oven)
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If there is anything else you would like to share or clarify, please do so below.
A picture of your dog may be helpful, if you'd like, please add below, as well any other information you think may be helpful!
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Please sign and date, if you understand and agree to the following: Neither Mirage & Marrow nor Kiara Bailey are a substitute for a veterinarian's care and advice. As the dog's owner you are responsible for the risk incurred in using home-prepared diet formulations and feeding raw foods and raw bones to your dog.
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