About Your Dog Dog's Name:  * Breed or Description:  *   Health & Behavior History Birthdate or Age:  *   Please Select One: Neutered Male Spayed Female Non-neutered male under 8 months Non-spayed female under 8 months   Please Check all Boxes that Apply to Your Dog: Has been aggressive with another dog Has been aggressive with another dog while on a leash Has been aggressive over food or a toy Has been aggressive towards a person Has chewed up items such as beds or toys in the last year Has ingested a non-edible item in the last 2 years Has a sensitive stomach or is prone to vomiting or diarrhea Can jump fences or open gate latches Should not eat our home-made birthday cake (ingredients include hamburger rice peanut butter and Milk Bones) Do not use any scented grooming products   Describe any health conditions your dog has or has had in the past. Any Allergies to Medications Food or Insects etc.? Anything else we should know about best caring for your dog? Regular Veterinary Clinic: Clinic Phone Number:   Your Contact Information Your First Name:  * Your Last Name:  * Street Address:  * City State and Zip  * Home phone number:  * Work phone number: Cell phone number: Last 4 digits of your Drivers License number  * This is a required security code that allows you to make changes or additions to this form via telephone or email such as adding someone to the list of people allowed to pick up your dog.     Additional Contact Person(s): Spouse / Friend / Family Member (Strongly Recommended) First Name Last Name Home phone number: Work phone number: Cell phone number: In addition to myself and my 2nd contact person the following persons are authorized to pick up my dog. (A photo ID may be required) Your email address - so we can let you know that we've received your updated form. Do not enter anything in this field:

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