New Dog Form

Your Name *

First Name Last Name

Your Dog's Name *

Breed *

Color *

Date of Birth

Sex *

Male

Female

Spayed or neutered? *

Yes

No

Unsure

Previous Veterinarian

Vaccine History

DHPP

Rabies

Bordetella

Lepto

Corona

Lyme

Vaccines given by

Microchip Number

On Heartworm Preventive?

On Flea Preventive?

Medical History (Please note any known illnesses, allergies, medical problems, major surgery, current medications.)

Housing & Travel History

Where does your dog sleep?

Outdoors

House

Garage

Doghouse

Other (please specify below)

Other

Type of Bedding

Expected Activities

Ride in car/truck

Hunt

Board

Jog

Play in Ocean

Other (please specify)

Other Activity

Additional Plans

Dog Shows

Obedience Training

Working Dog

Service Dog

Diet History (Please give us a complete picture of your dog’s diet, including treats. Use brand names if possible.)

Are there other pets in the house?

None

Dog(s)

Cat(s)

Other

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Vaccine History

Housing & Travel History