Intake Form
First name
Last name
Additional Owner:
Street Number
Apartment
City
ZIP
Phone number
Additional Number
How did you find us?
If referred, please include name of owner and/or dog
Veterinarian Name
Veterinarian Number
Dog #1 Name*
Dog #1 Breed*
Dog #1 Age*
Dog #1 Color
Dog #1 Weight
Dog #1 Gender*
Male
Female
Dog #1 Condition*
Spayed/Neutered
Unaltered
Any health issues?*
Yes
No
If yes, please explain:
Social Information*
Good with other dogs
Good with other people
No bite history
Has dog issues
Has people issues
Has bitten a person
Has bitten a dog
Please elaborate
Do you have any other dogs you'd like to add?
Yes
No
Dog #2 Name
Dog #2 Breed
Dog #2 Age
Dog #2 Color
Dog #2 Weight
Dog #2 Gender
Male
Female
Dog #2 Condition
Spayed/Neutered
Unaltered
Any health issues for dog two?
Yes
No
If yes, please explain for dog two:
Social Information for dog two:
Good with other dogs
Good with other people
No bite history
Has dog issues
Has people issues
Has bitten a person
Has bitten a dog
Dog #1 Food Name*
Dog #1 Cups per feeding*
Dog #1 Time of Feeding*
Check the box if true
Dog #1 Special Feeding Instructions
Dog #2 Food Name
Dog #2 Cups per feeding
Dog #2 Time of Feeding
Check the box if true
Dog #2 Special Feeding Instructions
Behavior Issues*
Additional Notes