Date of Birth *

MM

DD

YYYY

Vaccinations *

*Please note all dogs must be up to date on vaccines listed below, and records must be provided upon consultation*

Rabies

DHPP

Bordetella

Is your dog? (click all that apply)

Leash reactive

Toy possessive

Food possessive

Fear reactive

Dog aggressive

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Secondary Phone

(###)

###

####

Name of Secondary Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

Veterinarian's Name

First Name

Last Name

Clinic Phone *

(###)

###

####

Clinic Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is your dog crate trained?

Yes

No

Working on it

Does your dog do any of these behaviours? Click all that apply.

Counter surf (jump on counters/tables)

Get into trash

Dig under fences

Jump/climb fences

Eat/chew bedding and/or toys

Have accidents in the house

Chew on furniture