Today's date (mm/dd/yyyy):

Pet's name:

Parent's names (list all parents):

Address:

City, State Zip:

Home Phone:

Work Phone:

Cell Phone:

Emergency Phone:

Email Address:

Date of birth (mm/dd/yyyy):

Sex: Male Female

Breed: Color:

Medical History

Current Veterinary Clinic:

Neutered/Spayed: Yes No

Any known medications or allergies?

Please describe any medical or health issues we need to be aware of (ex: seizures, heart problems, joint problems...)

Microchip number and brand:

Rabies due:

DHLPP due:

Bordatella due:

Corona:

Lyme:

Heartworm test due:

Monthly Heartworm Preventative due:

Do you use any flea or tick preventative? Yes No

If Yes, what product:

Dog Profile

How long has your dog been in the family:

Where did you get the dog from?

If adopted, do you know the history?

How many people are in your family? 1 2 3 4 5 6 7 8 9 10 11 12

Men 0 1 2 3 4 5 6 7 8 9 10 11 12 Women 0 1 2 3 4 5 6 7 8 9 10 11 12

Kids 0 1 2 3 4 5 6 7 8 9 10 11 12 Ages:

Has your dog had any obedience training? Yes No

What level? Beginner Advanced CGC Therapy

Do you use a crate? Yes No

Is the dog comfortable in a crate? Yes No

Is your dog comfortable being handled and touched? Yes No

Has your dog ever climbed or jumped a fence? Yes No

Has your dog ever shown any signs of aggression towards anyone who's tried to touch his/her bone, food, or toys?

Yes No

Does your dog play with other dogs on a regular basis? Yes No

Which of the following does your dog prefer?

1. Male dogs Female dogs No preference Unknown

2. Puppies Adult dogs No preference Unknown

3. Small breed dogs Large breed dogs No preference Unknown

Please describe any additional behaviors we should be aware of:

Signature: