Owner Information

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Cell Phone: *

Email Address *

Emergency Contact:(if you cannot be reached) *

Phone Number: *

Current Veterinarian: *

Phone Number: *

How did you hear about us?: (check all that apply) *

Please Specify*

What services are you interested in? *

Daycare	Boarding
Spa	Other Other

Why are you considering our off-leash dog play program for your dog? (check all that apply) *

Pet Profile

Dog's Name: *

Breed/Description: *

Spay/Neuter *

Date: *

Birthday: *

Weight: *

Color: *

Health History: (check any that have occurred in the last year)

Please explain any health conditions listed above:

Please list any current or ongoing medications:(including flea and tick preventative and heartworm preventative)

Does your dog have any sensitive areas on his/her body? *

Yes

No

If yes, where?

Is your dog comfortable being crated? *

Yes

No

How would you describe the energy level of your dog? *

Low

Medium

High

Check the box below that best represents your dog's overall level of exercise routine: *

Couch Potato: Spends days sleeping, occasional walks and/or playtime with humans or other dogs.

Mild Exerciser: Short daily walks and/or regular playtime with human or other dogs.

Moderate Exerciser: Long or multiple walks daily and/or regular playtime with human or dogs.

Athlete: Regular jogs/runs and/or regular participation in a dog sport activity such as agility, flyball, frisbee, etc.

Which of the following best describes your dog's level of socialization with other dogs: *

None - No knowledge of other dog interaction	Minimal - On leash encounters only
Moderate - Some off-leash playtime on occasion with visitor's/neighbor's/friend's dog(s)	Extensive - Regular visits to dog social events, off-leash dog parks, dog daycare, etc.

What type of dogs does your dog play with? *

Males and females	Only males
Only females	My dog has not played with other dogs

Please describe size, breed, & temperament of the other dogs.

Are there any types and/or breeds of dogs your dog seems to automatically fear or dislike? *

Yes

No

If yes, please describe:

Has your dog had any problems previously in an off-leash social environment? *

Yes

No

If Yes, check all that apply

Altercation or fight at a public dog park	Altercation or fight with a neighbor or friend's dog
Fearful reaction in a group of dogs	Dismissed from a prior dog daycare or social playgroup program
Other (please describe) Other (please describe)

Only complete if your dog was dismissed from another program. What reason were you given as to why your dog was dismissed?

Only complete if your dog was dismissed from a prior program due to an incident. (check all that apply)

My dog was injured, no medical treatment required	My dog was injured and required medical treatment
Another dog was injured, no medical treatment required	Another dog was injured and required medical treatment
A person was injured, no medical treatment required	A person was injured and required medical treatment

Provide any other comments you want us to know about this situation.

Please check any behaviors below that your dog exhibits:

Please explain:

Has your dog ever growled at someone? *

Yes

No

If yes, what were the circumstances and how did you respond?

Has your dog every bitten someone? *

Yes

No

If yes, what were the circumstances and how did you respond? Please describe injuries (if any).

Has your dog ever bitten another animal? *

Yes

No

If yes, what were the circumstances and how did you respond? Please describe injuries (if any).

Does your dog have any problems in any of the following areas?

If yes, please explain:

Which commands does your dog know? (please check all that apply)

Which of the following best describes the use of obedience cues with your dog at home? *

Community Event*	Internet Search*	Veterinarian/Trainer*
Shelter/Rescue	Drive-by	Existing Client*
Advertisement	Saw Brochure/Business Card	Other Other

Play with other dogs	So not home alone
Exercise	Recommended by other pet professional(trainer, vet,etc)
Other Other

Allergies	Ear Infections	Worms (heart/tape)
Canine Cough	Eye Infections	Gastritis/Bloat
Seizures	Pancreatitis	Surgeries Surgeries

Incident involving another dog	Incident involving a person	Showing signs of aggression
Severe separation anxiety	Health issues	Other Other

Fear of strangers	Separation anxiety	Food aggression	Toy aggression or possession
Leash aggression	Dislikes puppies	Fear of storms	Other (fears or concerns) Other (fears or concerns)

Mouthing	Housetraining	Barking
Digging	Ignoring commands	Fence climbing/jumping
Escaping from house/yard	Can escape crate

Key part of daily communication	Used when we go on walks or have people over
Used occasionally to better control behavior	Rarely used
Not applicable

Sit	Stay	Down	Off	Come
Heel	Rollover	Kisses	High Five	Other Other