Name *

First Name

Last Name

Phone *

(###)

###

####

Date *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Sex

Male

Female

Problem Behaviors *

Bites

Play-Bites

Nipping

Growls

Mouthing

Teething

Aggressive

Unpredictable

Destructive

Fights with Dogs

Unruly

Barks

Jumps Up

Shy

Piddles

Cowers

Motion Sickness

Other (explain below)

None

Do you use a crate? *

yes

no

Is your dog house trained? *

yes

no

Do you have a fenced yard? *

yes

no

Do you have an underground fence? *

yes

no

Do you walk your dog on a lead? *

yes

no

Do you allow your dog to free feed throughout the day? *

yes

no

Does your dog show food aggression towards you, your family, or other pets when he/she eats? *

yes

no