Owner's name: Address:
City: State: Zip Code:
E-Mail: Phone (Home): Phone (Cell):
Dog's name: Breed: Age:    Years      Months
Sex (M/F): Neutered/spayed (Y/N):     Weight: Ever been kenneled? (Y/N):
If yes, briefly explain any problems reported:
Are behavioral problems new? (Y/N):
If yes, how long have they been going on?:
Is your dog on any prescriptions meds? (Y/N):
If yes, tell us what they are:
How much time is your dog alone each day?:
Have you done any training with your dog before?:

Please type Y or N in the boxes below:
House Soils:
Chews on things:
Digging:
Chases people:
Chases cars:
Mouthing:
Jumps on people:
Over barking:
Bites:
Bite reported:
Skin broken:
Stitches needed:
Fights with dogs:
Does not come when called:
Roaming:
Shyness with people:
Is your dog anxious?
Diet troubles:
Eats stools:
Car sickness:
Exercise off property (describe what type and frequency):
Exercise Other (please describe):
Please provide any other significant information about your dog:

Thank you for your patience as we respond to your inquiry.