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YAY Dog! New Client Intake Form
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* Indicates required question
Email
*
Your email
Today's Date
MM
/
DD
/
YYYY
Your Name
*
First Last
Your answer
Your Dog's Name
Your answer
Contact Number
*
(xxx)xxx-xxxx
Your answer
Address
House Number/Street, City, Zip
Your answer
Contact Preference
I prefer this
Ok, but not ideal
Do not contact me this way
Phone Call
Text Message
Email
Snail Mail
I prefer this
Ok, but not ideal
Do not contact me this way
Phone Call
Text Message
Email
Snail Mail
Clear selection
Is your dog's rabies vaccination up to date?
Please make sure your dog has its rabies shot and bring current vaccination record to our first meeting
Yes
No
Clear selection
Dog's Age
Approximate is OK
Your answer
How long have you had your dog?
select the closest approximate answer
less than a year
about a year
2-4 years
5 years or more
Clear selection
How did you find your dog?
Your answer
How healthy is your dog?
None
Mild
Moderate
Severe
Age-related symptoms (e.g., arthritis, incontinence)
Underweight
Overweight
Chronic Illness (e.g. Lyme)
Temporary Illness
Temporary Injury
Permanent Injury or Disability
Cognitive or Mental Disability
None
Mild
Moderate
Severe
Age-related symptoms (e.g., arthritis, incontinence)
Underweight
Overweight
Chronic Illness (e.g. Lyme)
Temporary Illness
Temporary Injury
Permanent Injury or Disability
Cognitive or Mental Disability
Clear selection
What brand of food do you feed your dog?
Your answer
Who lives in the household?
# Adult Women, # Adult Men, # Children; name and age of each ; Also list other animal with name and age of each
Your answer
What outcome do you envision for you and your dog from our work together?
List 1 or 2 behaviors. Please be specific. (Ex. "stop jumping on visitors" instead of "behavioral changes." )
Your answer
Has your dog ever bitten someone?
No
Yes, a person
Yes, an animal
Yes, both a person and an animal
Clear selection
How did you hear about me?
Google
Oliver's Collar
Other End of the Leash
Barnes Supply Co.
Paws at the Corner
Facebook
Vet Referral
Friend Referral
Instagram
Other:
Clear selection
Please list 1-3 questions you would like me to answer
Your answer
What day/time would you be available for a YAY Dog appointment? Please list weekend or weekday, specific days or time of day
Your answer
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