YAY Dog! New Client Intake Form
Today's Date
Your Name *
First, Last
Your Dog's Name
Contact Number *
House Number/Street, City, Zip
Contact Preference
I prefer this
Ok, but not ideal
Do not contact me this way
Phone Call
Text Message
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
Clear selection
Dog's Age
Approximate is OK
How long have you had your dog?
select the closest approximate answer
Clear selection
How did you find your dog?
How healthy is your dog?
Age-related symptoms (e.g., arthritis, incontinence)
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?
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?
Clear selection
How did you hear about me?
Clear selection
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
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy