NEW CLIENT QUESTIONNAIRE | City Dogs, Roanoke

Please complete the form below. Note that we have included space for information on up to four dogs as many of our customers are multiple dog owners. The button to send the form is at the very end (keep scrolling, thanks for your patience).

Fields marked with * are required.

PRIMARY OWNER

FIRST OWNER'S NAME *

HOME PHONE *

MOBILE PHONE

WORK PHONE

EMAIL *

CONFIRM EMAIL *

STREET ADDRESS *

CITY *

STATE *

ZIP CODE *

SECOND OWNER

SECOND OWNER'S NAME (OPTIONAL)

HOME PHONE

MOBILE PHONE

WORK PHONE

CONFIRM EMAIL

STREET ADDRESS

CITY

STATE

ZIP CODE

WHO MAY PICK UP YOUR DOG(S)

PERSON #1 NAME

YOUR RELATIONSHIP TO PERSON #1

PERSON #2 NAME

YOUR RELATIONSHIP TO PERSON #2

VETERINARIAN

DOCTOR'S NAME *

CLINIC NAME *

CLINIC PHONE *

CLINIC STREET ADDRESS

CLINIC CITY *

CLINIC STATE *

CLINIC ZIP CODE *

DOG #1 DESCRIPTION

DOG #1 NAME *

BREED *

AGE (YRS) *

WEIGHT (LBS) *

COLOR *

MARKINGS

SEX *

HOW LONG HAVE YOU OWNED THIS DOG (MONTHS / YEARS)? *

WHERE WAS THIS DOG ACQUIRED FROM? *

IF OTHER, EXPLAIN

IS YOUR DOG HOUSE TRAINED? *
YesNo

IS YOUR DOG CRATE TRAINED? *
YesNo

HOW ACTIVE IS YOUR DOG DURING THE DAY? *

WHO IS YOUR DOG AROUND DURING THE DAY? *

DOES YOUR DOG HAVE ANY FOOD ALLERGIES? *
YesNo

IF OTHER, EXPLAIN

IS YOUR DOG ON A SPECIAL DIET? *
YesNo

IF YES, EXPLAIN

DOES YOUR DOG HAVE ANY MEDICAL CONDITIONS? *
YesNo

IF YES, EXPLAIN

IS YOUR DOG ON ANY MEDICATIONS? *
YesNo

IF YES, EXPLAIN

PLEASE SELECT AS MANY AS APPLY TO YOUR DOG *

YOU SEE THIS BEHAVIOR WITH *
All dogsCertain dogs

EXPLAIN

IN WHAT SITUATIONS DOES THE BEHAVIOR OCCUR?

ANY OTHER SPECIAL REQUIREMENTS OR DETAILS WE SHOULD KNOW ABOUT YOUR DOG IN ORDER TO GIVE THEM THE BEST CARE?

DOG #2 DESCRIPTION

DOG #2 NAME

BREED

AGE (YRS)

WEIGHT (LBS)

COLOR

MARKINGS

SEX

HOW LONG HAVE YOU OWNED THIS DOG (MONTHS / YEARS)?

WHERE WAS THIS DOG ACQUIRED FROM?

IF OTHER, EXPLAIN

IS YOUR DOG HOUSE TRAINED? *
YesNo

IS YOUR DOG CRATE TRAINED? *
YesNo

HOW ACTIVE IS YOUR DOG DURING THE DAY? *

WHO IS YOUR DOG AROUND DURING THE DAY? *

DOES YOUR DOG HAVE ANY FOOD ALLERGIES? *
YesNo

IF OTHER, EXPLAIN

IS YOUR DOG ON A SPECIAL DIET? *
YesNo

IF YES, EXPLAIN

DOES YOUR DOG HAVE ANY MEDICAL CONDITIONS? *
YesNo

IF YES, EXPLAIN

IS YOUR DOG ON ANY MEDICATIONS? *
YesNo

IF YES, EXPLAIN

PLEASE SELECT AS MANY AS APPLY TO YOUR DOG *

YOU SEE THIS BEHAVIOR WITH *
All dogsCertain dogs

EXPLAIN

IN WHAT SITUATIONS DOES THE BEHAVIOR OCCUR?

ANY OTHER SPECIAL REQUIREMENTS OR DETAILS WE SHOULD KNOW ABOUT YOUR DOG IN ORDER TO GIVE THEM THE BEST CARE?

DOG #3 DESCRIPTION

DOG #3 NAME

BREED

AGE (YRS)

WEIGHT (LBS)

COLOR

MARKINGS

SEX

HOW LONG HAVE YOU OWNED THIS DOG (MONTHS / YEARS)?

WHERE WAS THIS DOG ACQUIRED FROM?

IF OTHER, EXPLAIN

IS YOUR DOG HOUSE TRAINED? *
YesNo

IS YOUR DOG CRATE TRAINED? *
YesNo

HOW ACTIVE IS YOUR DOG DURING THE DAY? *

WHO IS YOUR DOG AROUND DURING THE DAY? *

DOES YOUR DOG HAVE ANY FOOD ALLERGIES? *
YesNo

IF OTHER, EXPLAIN

IS YOUR DOG ON A SPECIAL DIET? *
YesNo

IF YES, EXPLAIN

DOES YOUR DOG HAVE ANY MEDICAL CONDITIONS? *
YesNo

IF YES, EXPLAIN

IS YOUR DOG ON ANY MEDICATIONS? *
YesNo

IF YES, EXPLAIN

PLEASE SELECT AS MANY AS APPLY TO YOUR DOG *

YOU SEE THIS BEHAVIOR WITH *
All dogsCertain dogs

EXPLAIN

IN WHAT SITUATIONS DOES THE BEHAVIOR OCCUR?

ANY OTHER SPECIAL REQUIREMENTS OR DETAILS WE SHOULD KNOW ABOUT YOUR DOG IN ORDER TO GIVE THEM THE BEST CARE?

DOG #4 DESCRIPTION

DOG #4 NAME

BREED

AGE (YRS)

WEIGHT (LBS)

COLOR

MARKINGS

SEX

HOW LONG HAVE YOU OWNED THIS DOG (MONTHS / YEARS)?

WHERE WAS THIS DOG ACQUIRED FROM?

IF OTHER, EXPLAIN

IS YOUR DOG HOUSE TRAINED? *
YesNo

IS YOUR DOG CRATE TRAINED? *
YesNo

HOW ACTIVE IS YOUR DOG DURING THE DAY? *

WHO IS YOUR DOG AROUND DURING THE DAY? *

DOES YOUR DOG HAVE ANY FOOD ALLERGIES? *
YesNo

IF OTHER, EXPLAIN

IS YOUR DOG ON A SPECIAL DIET? *
YesNo

IF YES, EXPLAIN

DOES YOUR DOG HAVE ANY MEDICAL CONDITIONS? *
YesNo

IF YES, EXPLAIN

IS YOUR DOG ON ANY MEDICATIONS? *
YesNo

IF YES, EXPLAIN

PLEASE SELECT AS MANY AS APPLY TO YOUR DOG *

YOU SEE THIS BEHAVIOR WITH *
All dogsCertain dogs

EXPLAIN

IN WHAT SITUATIONS DOES THE BEHAVIOR OCCUR?

ANY OTHER SPECIAL REQUIREMENTS OR DETAILS WE SHOULD KNOW ABOUT YOUR DOG IN ORDER TO GIVE THEM THE BEST CARE?

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