Pet Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Contact #2/Spouse Name

First Name

Last Name

Phone

(###)

###

####

Emergency Contact

First Name

Last Name

Phone

(###)

###

####

Has your dog experienced any of the following conditions?

Check all that apply.

Chronic Health Conditions

Persistent Injuries

Seizure

Stroke

Other

Does your dog:

Have a sensitive stomach?

Have any known general allergies?

Have allergies to shampoos/perfumes?

Is your dog on a monthly flea regimen? *

Yes

No

Has your dog socialized with other dogs before?

Yes, at a dog park

Yes, at other kennels

Yes, at home or with friends' dogs

No, not yet

Has your dog ever:

Bitten a person?

Been in a fight with/bitten another dog?

Refused service at a grooming, daycare, boarding, or veterinary facility?

Has your dog ever:

Climbed/jumped a fence

Dug under a fence

Is your dog known to:

Try to escape

Chew/shred

Bark excessively

Dog's Crate Behavior *

Content

Anxious

Destructive

Unknown

Other

Is your dog sight or sound sensitive to:

Thunderstorms

Blow dryers

Vacuums

Other