Client Information Registration General Information (to be completed by client) Client Information Registration Client: * Date: * Occupation : Number of Children in Household: Other Pets: Street Address: * City: * State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code: * Home Phone Number: * Work Phone Number: Other Phone Number: Emergency Phone Number: * Email Address * Who else has permission to pick up your dog: Dog's Name: * Breed * Color : * Approx. Weight: * Age: * Sex: * MaleFemale Spayed/Neutered: * YesNo Where did you get your dog: * Price paid if purchased: How old was your dog when obtained: Referred by: Are you interested in using our Pick up/Drop off Service: YesNo ALL dogs must be spayed/neutered to join in group play. Top Dog must have proof of vaccines BEFORE entering the premises. We will also need proof that your dog is on Flea/Tick & Heart worm preventative. Behavior Interview Checkboxes House soils away Chews Digs Jumps up Disobeys Shy Pica/Corpo Self mut Runs Barks Is this the first dog you have owned as an adult: YesNo Has your dog growled, snapped, or bitten you or anyone else? Explain: Does your dog get nervous around strangers or new situations? Explain: Has your dog ever socialized with a large group of dogs (more than 6)? Explain: If your dog is 40 lbs or heavier has he/she played with small dogs (15 lbs or less)? Explain: If your dog is 15 lbs or less has he/she ever played with larger dogs (40 lbs or heavier)? Explain: Has your dog ever been bitten by another dog? Explain : Has your dog shown aggression towards other dogs? Explain: Is there anywhere on your dog’s body he/she doesn’t like to be touched? Explain: Will your dog easily share toys with people/ dogs or does he/she guard them? Do you tend to “spoil” your dog? Yes No Is your dog like a child to you? Yes No Does your dog “nudge” you for petting? Yes No Do you think your dog has ever been mad at you? Yes No Do you think your dog has done something to be spiteful? Yes No Do you constantly repeat commands for your dog to listen? Yes No Are you consistent in your expectations of your dog’s behavior? (Do you sometimes allow certain behaviors and sometimes not allow the same behaviors) Explain: How do you discipline your dog?: Does it work?: Have you ever punished your dog for house soiling?: Yes No Does your dog live in the house?: Yes No If your dog does not live in the house, where does he live and why?: Is your dog allowed on furniture?: Yes No In your bed?: Yes No Does your dog get upset when left alone?: Yes No What does your dog do when left alone at home?: Do you confine you dog away from you? : Yes No How much exercise does your dog receive on a daily basis, please explain?: Do you allow your dog off leash? : Yes No Sometimes Does your dog listen off the leash?: Yes No Sometimes Would you consider your dog an escape artist?: Yes No Do you have a fenced in yard? : Yes No Has your dog ever jumped a fence or barrier? : Yes No Health Information Does your dog have any chronic illnesses?: Yes No Does your dog have a history of “hot spots” ?: Yes No Please list any pre-existing medical conditions or surgeries?: Does your dog have any allergies? Explain: Is your dog on any medication and frequency of use? Explain: Heartworm or Flea/Tick prevention: Yes No Has your dog ever been to the Vet for an emergency? : Yes No Heartworm or Flea/Tick prevention frequency: Veterinarian and Vet Phone: Vaccination records: Annual Rabies Bordatella Worming Date of last Vet check: Diet Information Has your dog been kenneled before?: Yes No Does your dog board well?: Yes No Where/When was your dog boarded: If dog does not board well, explain: Dog food brand: Cups per day: Frequency of meals: Does your dog have special feeding instructions? Explain: Eating habits: Eats all food at one time Nibbles throughout the day Goes for periods without eating Have to mix in food to encourage him/her to eat OtherOther There is a $1 per meal fee if we need to mix 2 or more items in their food. Does your dog growl at you if you get near his/her food?: Yes No Can you easily take your dog’s food away when he/she is eating? : Yes No In your opinion, your dog is: Ideal weight Over weight Underweight Overall Attitude of the Dog (Check all that apply) High energy level Medium energy level Low energy level Excited Happy Greets trainer readily Nervous reservedly Greets trainer reservedly Gains confidence Doesn’t gain confidence after greeting trainer Aloof Frightened/Shy Does not approach Avoids greeting trainer Shows aggression Growls Snaps Bites Other commentOther comment Eternal parasites (fleas & ticks): Yes No Other: Eyes clear Gums normal Ears clean Coat healthy Normal gait Ideal weight Overweight Underweight Explanations:
