Please fill in the following information and return before your scheduled appointment:
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Primary Phone:
Alternate Phone 1:
Alternate Phone 2:
E-mail:
If you are requesting an appointment for your animal, please fill in the section below:
Animal's Name:
Species:
Dog
Horse
Cat
Bird
Other Species:
Age:
Sex:
Spayed/Neutered?
Male
Female
Yes
No
Breed:
Add a photo of you and/or your animal:
(not required)
(.gif or .jpg format please)
HISTORY
Please Be Specific and Complete
How long has this animal been with your family?
How did this animal come to be with your family?
Describe your animals diet, including food & supplements, as well as eating habits:
Describe the exercise your animal gets:
Do you and your animal companion participate in any sports or activities together?
Yes
No
Describe:
What are the things you like most about your animal friend?
What are the Wellness or Behavioral issues that you would like to change or improve?
(Please list all and be specific, including the duration & circumstances -
also see the checklist below)
How have you (and/or your vet) attempted to assist your animal with these issues and what were the results?
Please use this checklist to help you consider your animals challenges.
Check all that apply.
Personality Type:
Friendly /
Outgoing
Aloof
Shy
Eager
to Please
Lethargic
Fearful
Hyperactive
Nervous
Temperamental
Unable to Focus
Other:
Fears / Resistances / Social Skills:
Afraid
of Strangers
Loud Noises
Thunderstorms
Nail Clipping
Brushing
Grooming
Teeth Cleaning
Vet Visits
New
Environments
Car Sickness
Other Animals
Different Surfaces/Footing/Stairs
Spraying/Litter Box Issues
Leash Pulling
Jumping Up
Digging
Chewing
Excessive
Licking
Running Away
Submissive Urination
Excessive Vocalizing
Feather Pulling
Other:
Aggressive Behavior:
Strange Adults
Strange Children
Family Members
Dogs
Cats
Other:
Growling
Hissing
Scratching
Biting
*
*
LEVEL OF BITE
:
Light • Did Not Break Skin
Mild • Skin Break/Bruise
Moderate • First Aid Required
Severe • Required Visit To Hospital/Vet
Deadly • Resulted In Disfigurement Or Death
Comments:
Wellness Concerns:
Aging
Arthritis
Dysplasia
Incontinence
Illness
Injury
Surgery
Describe:
Performance / Breeding Concerns:
Stress
Show Anxiety
Performance
Gait/Conformation
Whelping/Breeding
Describe:
Other Comments / History of Animal
How did you hear about Dancing Hearts?
I have read the
Statement of Disclosure and Client Agreement
and by submitting this form, I agree to abide by the terms of that agreement.