Client Intake Form Contact Information Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * How did you hear about us? * Friend Google Facebook Instagram Howard County Rec & Park Activity Guide Other Emergency Contact Information Name * First Name Last Name Phone * (###) ### #### Relationship Dog 1 Information Name * Date of Birth * MM DD YYYY Breed * Sex * Male Female Color/Markings Likes Dislikes Temperament Commands your dog already knows. Veterinarian Information Clinic Name and Veterinarian * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Would you like us to update your veterinarian about your dog's training? * Yes No Dog Medical History Past and Current Illnesses Current Medications Any illnesses or surgeries in the past 12 months? Yes No If so, please elaborate Are your dog's vaccinations up to date? Yes No Is your dog spayed/nuetered? Yes No Training Details Which service are you interested in? * Private Lessons Board and Train Group Classes Private Lesson/Day Training Fusion Boarding Preferred Start Date MM DD YYYY What behaviors/issues are you planning to resolve: Aggression/Biting Fear/Anxiety Jumping Digging Barking Pulling On Leash Listening Around Distracions Other Other behavioral issues: What have you done before to try to resolve these issues? Has your dog done formal training before? Yes No Important details about the training you did: How did you hear about us? Google Facebook Vet Office Howard County Park and Recreation Montgomery County Recreation Other Thank you for filling out the form. We will be in contact with you shortly.