Address: ________________________________________________________
City: ________________________________________ State: ___ Zip: _______
Employer: _______________________________________________________
Best way to contact you:
Indicate the best order in which to contact you by numbering the phone numbers; 1,2,3,4 and the email: 1,2
__. Home#: _________________________ __. Work #________________________
__. Cell#: ___________________________ __. Pager #: _______________________
__. Home E-Mail: ______________________________________________________
__. Work E-Mail: _______________________________________________________
Yellow Pages___ Internet___ East Side Messenger____ Bonus Pak (Col Dispatch) ___
CnF Client___ Their name________________________________________________
Other ________________________________________________________________
Dog’s Name: ___________________________ Breed: _________________________
Age: _______ Birth date: _____________ Sex: _________
Spayed/Neutered? Yes___ No ___
If yes, approximate age ___________ if no, when will he/she be spayed/neutered _______
How long have you had your dog? _____________
Where did you get your dog?
Breeder___ Rescue Group ____ Pound/Shelter____ Owner Relinquish___
Other _______________________________________________________
What commands does your dog know?
None ___ Sit___ Stay___ Down___ Come___ Heal___ Wait___
Others____________________________________________________________
Has your dog been to training classes? Yes ___ No___
If yes, where _____________________________________________________
What level was completed? ____________________________________
Does your dog need to be with you or a member of your household all the time?
Yes ___ No___ Somewhat ___
Does your dog entertain itself? Yes ___ No___ Somewhat ___
Is your dog afraid of loud noises? Yes ___ No___ Somewhat ___
Is your dog crate trained? Yes ___ No___ Somewhat ___
What is your dog’s energy level? Extreme__ High__ Medium __ Low__
Does your dog destroy their toys? Yes ___ No___ Sometimes ___
If yes, what kind of toys ____________________________________________
Are there any behavioral issues we need to be aware? Yes ___ No___
If yes, please explain_______________________________________________
Give a brief description of your dogs personality ______________________________
______________________________________________________________________
______________________________________________________________________
Will your dog jump or climb a 6ft fence? Yes ___ No___ Maybe ___
If yes, explain the circumstances ______________________________________
Does your dog dig? Yes ___ No___ Sometimes ___
If yes, explain the circumstances______________________________________
Is your dog food (__) or toy (__) protective? Yes ___ No___ Somewhat ___
If yes, please explain _______________________________________________
Has your dog shown any aggression toward people or other dogs? Yes ___ No ___
If yes, please explain: _______________________________________________________________
_______________________________________________________________
Will there be any other people picking up your dog other than yourself? Yes ____ No __
If yes, please provide their name:
__________________________ ______________________________
__________________________ ______________________________
Is your dog on any medications or have any medical problems? Yes___ No ___
If yes, please explain:
__________________________________________________________________________________________________________________________________________________________________________________________________________________
Has your dog been tested for worms? Yes ___ No ___
If positive, has your dog been treated and is now free from any parasites? Yes___ No___
Is your dog on heartworm preventative? Yes___ No___
In case of emergency, and after reasonable attempts to contact you have been made, are we authorized to transport your dog to a veterinarian?
Yes ___ No__
Preferred Clinic/Veterinarian: _____________________________________________
Address: __________________________________________________
Phone: ____________________________________________________
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Vaccination |
Date Given |
Due Again |
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DHLPP |
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Rabies |
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Bordetella |
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Parvo Booster |
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Heartworm Prev. |
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Flea Prev. |
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Fecal Test |
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Veterinarian Signature: _________________________________ Date: _____________
Receipts from the vet showing date of vaccinations can be used in lieu of the above form being completed by your veterinarian.