Intake Form | Kristina's Critters

Name *

Date *

Dog’s Name *

Breed *

Age/Sex: *

Spay/Neut.? *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Referred by *

Other Pets in Household *

Other People in Household *

Occupation/Time spent outside home *

Veterinarian *

Medical Problems/Meds/Allergies *

Date of Last Rabies Vaccination *

Expiration *

Brand of Food *

How many times per day? *

What times is dog fed? *

Eat right away/finish meals? *

Other treats/snacks & how often *

Where was dog obtained/How long ago *

Housebroken? *

Crate trained? *

Where does dog sleep? *

% time indoor/outdoor? *

Where kept when owner gone? *

Any previous training? Behaviors dog knows/training methods used/trainer: *

Exercise Type/Frequency *

Equipment used on walks *

Has dog ever bitten or injured a person or animal? ____ (If yes, describe in Notes section) Reason for Consultation: *

Message *