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: If my dog needed to be kenneled for a medical or behavioral reason he might chew up or ingest pieces of a dog bed Please do not use any scented grooming products on my dog while he is at Woof Dah! My dog is prone to diarrhea vomiting or has a sensitive stomach My dog shouldn't eat our homemade birthday cake (Made from hamburger rice peanut butter and milk bones) My dog has been aggressive with another dog My dog has been aggressive while greeting another dog on a leash My dog has been aggressive over food or toys My dog has been aggressive towards a person My dog has bitten another dog or a person   Please provide details (if appropriate) for any boxes that you checked above: Describe any health conditions your dog has or has had in the Past. (Example: Chronic Ear Infections Pancreatitis in 2006 ACL Surgery on Right Knee in 2008 etc) 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: (Strongly Recommended) Their First Name: Their Last Name: This person is a: Friend Family Member Significant Other Spouse This person is: Not an Owner of the Dog Also an Owner of the Dog Their home phone number: Their work phone number: Their 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:  * Comments or questions about this form: Mailing list signup:   Check this box to ensure that your email address has been registered in our mailing list so that we can advise you of any health alerts. Security code:   * Do not enter anything in this field: