Name

Cell Phone

Email Address

Address

City

State

Zip Code

Please list other adults living in the home

Children Names and Ages

Who may I thank for your referral?

Dog's Name

Age

Age When Acquired

Breed

Was your dog a rescue? Was your dog a rescue? Yes No

Rescue Name

Breeder Name

Spayed / Neutered Spayed / Neutered Yes No

Veterinarian/Animal Hospital

Medications - Past & Present - Allergies?

Food - How much and what kind do you give your dog?

Fenced Backyard? Fenced Backyard? Yes No

House Trained? House Trained? Yes No

Crate Trained? Crate Trained? Yes No

How many hours does your dog spend alone each day?

Where do they spend their time when alone?

What is the dog's living environment like? (Apartment, townhouse, single family home, fenced yard, other animals, schedules)

What types of enrichment does your dog enjoy? (For example walks, jogs, puzzle toys, sniff walks, one on one play time)

What types of treats does your dog like?

What types of chew does your dog enjoy? (rawhides, bullysticks, stuffed Kongs...)

What types of toys does your dog like to play with?

History Known to You - Please provide specific details if known.

Social History - Does your dog get along well: with people? with children? with dogs? at daycare? in your home? at a park?

Has your dog had any prior training? (From you or someone else) If yes, please explain what was taught and how.

Has your dog ever bitten a person or another animal? If yes, please describe in as much detail as possible. (Who was around at the time? Where did the incident occur? What type of damage was done? How did you react?)

Behavioral Issues - Please provide as much detail as possible, describing specific concerning incidents as well as overall behavior issues.

What have you tried to resolve these issues?

What are your training goals for your dog(s)?

Other notes you would like to add: