Date of Birth *

Or best approximation.

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

Has your dog previously attended any daycare facility? *

Yes

No

Is your dog? (click all that apply)

Leash reactive

Toy possessive

Food possessive

Fear reactive

Dog aggressive

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

Is your dog crate trained?

Yes

No

Working on it

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