CLIENT PROFILE i understand the hours of operation are from 8:30am - 1:30pm * by checking this box you acknowledge our hours of operation from 8:30am - 1:30pm, M-F yes no your name * First Name Last Name email address * your home address * Address 1 Address 2 City State/Province Zip/Postal Code Country mobile number * (###) ### #### EMERGENCY INFORMATION emergency contact * emergency veterinarian * we recommend + share the same property as St. Helena Veterinary Hospital DOG PROFILE dog's name * microchip # * breed (s) * gender * date of birth * HEALTH + MEDICAL your dog's veterinarian * Address 1 Address 2 City State/Province Zip/Postal Code Country is your dog current on monthly preventatives (heartworm, fleas, tick)? * yes no if yes, list products given: * for example: NexGard (ticks, fleas), Interceptor (heartworm), etc. VACCINES rabies — veterinarian + clinic who administered vaccine * rabies — date given * MM DD YYYY rabies — due date for next vaccine * MM DD YYYY bordetella — veterinarian + clinic who administered vaccine * bordetella — date given * MM DD YYYY bordetella — due date for next vaccine * MM DD YYYY DHP — veterinarian + clinic who administered vaccine * distemper, hepatitis, parvovirus DHP — date given * MM DD YYYY DHP — due date for next vaccine * MM DD YYYY YOUR DOG'S PERSONALITY describe your dog's personality * Playful / Shy / Outgoing / Independent / Gentle / Confident / Submissive / Bossy describe your dog's energy level * low, medium, high, very high has your dog ever bitten a person? * if yes, please describe. has your dog bitten another dog? * if yes, please describe. has your dog escaped or run away from you or a caregiver? * if yes, please describe does your dog become unfriendly in any of these situations? * check all that apply around other dogs around other people touching ears, tails, feet, or mouth grabbing collar none of the above describe any unfriendly behavior * check all that apply moves away shows teeth freezes raises hackles growls snaps may bite will bite none of the above YOUR DOG'S TRAINING does your dog have a reliable recall? * we know it's not always easy... tell us about any formal training you and your dog have had * private instruction, group classes, competitive sports, etc. anything else you'd like to share with us brags, accomplishments, fun stuff thank you for taking the time to complete and sign our agreement!
