YAY Dog! New Client Intake Form
Today's Date
MM
/
DD
/
YYYY
Your Name *
First, Last
Your Dog's Name
Contact Number *
(xxx)xxx-xxxx
Address
House Number/Street, City, Zip
Email
Contact Preference
I prefer this
Ok, but not ideal
Do not contact me this way
Phone Call
Text Message
Email
Snail Mail
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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
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Dog's Age
Approximate is OK
How long have you had your dog?
select the closest approximate answer
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How did you find your dog?
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
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What brand of food do you feed your dog?
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
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." )
Has your dog ever bitten someone?
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How did you hear about me?
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Please list 1-3 questions you would like me to answer
What day/time would you be available for a YAY Dog appointment? Please list weekend or weekday, specific days or time of day
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