Warsaw Dog Survey Owner details: Dog details: Vaccinations:

Transcription

1 Customer number Warsaw Dog Survey Owner details: Name and Surname: ID: Primary phone: Emergency phone: Address: Postal code: -, Dog details: Breed: Name: Sex: Weight: kg Chip / tattoo: Age: Vaccinations: Has the dog been recently vaccinated against rabies? Yes No Has the dog been recently vaccinated against infectious diseases? Yes No Has the dog been recently vaccinated against kennel cough? Yes No Has the dog been dewormed in last three months? Yes No Has the dog been protected against fleas and ticks? Yes No The conditions of attending to The Warsaw Pethouse are to vaccinate the dog against all of the factors mentioned above and its regular deworming. I confirm that my dog meets the conditions described above. date and legible client signature T h e W a r s a w P e t h o u s e S t r o n a 1 5

2 State of health information: Has the dog been sterilized/neutered? Yes No *Date of the last in heat: The planned date of sterilization/castration: Is the dog healthy? Yes No *If no, what is the sickness? (Overweight, diabetes, dysplasia, etc.) Does your dog have any physical disabillities? Yes No *Please explain disabilities & cause *If answered yes, what restrictions need to be placed on your dog s activities or movements? No jumping No walking up stairs No running Other: Is the dog currently on any medication? Yes No *If yes, what kind of medication is it? (label, dosage and frequency of taking) Does the dog have epilepsy? Yes No Does your dog have any allergies? Yes No * If yes, please explain? Leading veterinarian details: Veterinarian name/clinic: Phone: Nourishment during dog daycare: Type of food: Own Puppy dry dog food Adult dry dog food Senior dry dog food Number of meals: Time to provide food: T h e W a r s a w P e t h o u s e S t r o n a 2 5

3 Dog behavior information: 1. Which of the following best describes your dog s level socialization? None No knowledge of other dog interaction, Minimal On leash encounters only, Moderate Some off-leash playtime on occasion with visitor s/friend s dog(s) Extensive Regular visit to dog social events, off-leash dog parks, dog daycare, etc. 2. Has your dog had any problems previously in an off-leash social enviroment? Yes No *If yes, check all that apply Altercation or fight at a public dog park Altercation or fight with a neighbor or friend s dog Fearful reaction in a group of dogs Other (Please describe) 3. Does your dog have any sensitive areas on his/her body? Yes No *If yes, where? 4. Check the box below that best represents your dog s overall level of exercise routine: Couch potato: Spands days sleeping, occasional walks and/or playtime with humans or other dogs Mild Exerciser: Short daily walks and/or regular playtime with human or other dogs Moderate Exerciser: Long or multiple walks daily and/or regular playtime with human or dogs Athlete: Regulat jogs/runs and/or regular participation in a dog sport activity such as agility, flyball.. 5. Are there any particular types o people your dog seems to automatically fear or dislike? Yes No *If yes, please describe: 6. How does your dog react to puppies? Good Neutrally Bad 7. Does your dog play with other dogs? Yes No If yes, which type? Male and females T h e W a r s a w P e t h o u s e S t r o n a 3 5

4 Only males Only females 8. Has your dog ever growled or snapped at another dog who has taken food or toys away from him/her? Yes No 9. How did your dog get his/her obedience training? Attended one group class Attended more than one level of group classes Sessions with a behaviorist at home Teaching dog by yourself Other (please, explain): 10. Which commands does your dog know? Sit Come Down Rollover Paw Leave Stay Other: 11. Does your dog have any problems in any of the following areas? Barking Digging Mouthing Ignoring commands Separation anxiety 12. Does your dog have any sensitive areas where he doesn t like to be touched? Yes No *If yes, please describe 13. What your dog doesn t like? (putting on a harness, bathing etc.) 14. Is your dog frightened or nervous around anything? (thunderstorms, cars) Yes No *If yes, please explain 15. Care recommendations (brushing, eyes cleaning, claws clipping etc.) 16. Why are you contact The Warsaw Pethouse? (multiple choice) My dog stays alone at home for few hours every day so I want to give him a little joy I work at home but I want my dog to spend more time with another dogs My dog has separation anxiety (barks a lot, destroys furniture etc.) I care about my dog s professional socialization I travel a so I m looking for a place where my dog will be safe T h e W a r s a w P e t h o u s e S t r o n a 4 5

5 My dog is fearful I want to help him and change it Others How do I know about Warsaw Pethouse: Facebook Media Booklet Friend Other I hereby declare that i have the Therms and Conditions of The Warsaw Pethouse and I agree to the presented there rule for provided services. I hereby admit into custody of The Warsaw Pethouse the above-described dog and items mentioned in the form (medication, accesories, etc.) under the conitions specified in the Regulations and above application form. I hereby consent to the processing by the Warsaw Pethouse Berger sp. K. the above personak data for marketing purposes. I hereby agree to receive commercial information from Warsaw Pethouse Berger sp. k. by either or telephone call, as well as to receive contract proposal by The Warsaw Pethouse Berger sp. k., using said methods of communication. Date and legible client signature I hereby confirm dog admittance by the Client. Date and legible WPH employee signature T h e W a r s a w P e t h o u s e S t r o n a 5 5