Pet Name *
Breed *
Sex * -- Please select one -- Male Female Neutered Spayed
Age *
Weight *
Color *
Is your pet spayed or neutered? * -- Please select one -- Yes No
If yes, at what age?
Has your dog ever stayed with us? * -- Please select one -- Yes No
First Name *
Last Name *
Address *
City *
State * -- Please select one -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine
Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota
Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code *
E-mail address *
Home Phone *
Cell Phone
Work Phone
Emergency Contact Name *
E-mail address *
Home Phone
Cell Phone
Work Phone
Animal Hospital Information
Animal Hospital Name *
Animal Hospital Phone *
Any serious medical conditions? Please explain.
Does your dog have any allergies? *
Is your dog on a special diet? *
Can your dog have treats? * -- Please select one -- Yes No
If yes, what type?
Is your dog on flea/tick preventative? * -- Please select one -- Yes No
If yes, what type?
Is your dog on heartworm preventative? * -- Please select one -- Yes No
If yes, what type?
Is your dog currently on medication? * -- Please select one -- Yes No
If yes, what type?
Has your dog had a fecal exam in the last 6 months? * -- Please select one -- Yes No
Does your dog have any physical limitations? *
How did you hear about Pampered Pets Day Camp? * -- Please select one -- Friend/Colleague Vet Referral Google Advertisement Search Engine Yellow Book CenturyLink/Dex Phone Book Link on Website Facebook Facebook Ad Craigslist Saw Your Business Location Existing Customer Other
Why have you chosen day camp for your dog? *
Has your dog ever been in day camp before? * -- Please select one -- Yes No
If yes, where and what was your reason for leaving?
How long have you had your dog? *
Where did you get your dog? *
If you did not get your dog as a puppy, what knowledge do you have of your dog's history?
Does your dog have any sensitive areas on his/her body that they are reactive to when touched? *
How does your dog like to receive affection? (ex. Belly rubs, kisses) *
Is your dog comfortable with women? * -- Please select one -- Yes No
Is your dog comfortable with men? * -- Please select one -- Yes No
Is your dog comfortable with children? * -- Please select one -- Yes No
Is your dog comfortable with strangers? * -- Please select one -- Yes No
If no to any of the above, please explain in detail.
Are there any types of people your dog automatically fears or dislikes? (ex. men with beards, people *
Has your dog ever growled at people? * -- Please select one -- Yes No
If yes, please explain circumstances.
Has your dog ever bitten someone? * -- Please select one -- Yes No
Did the bite break the person's skin? -- Please select one -- Yes No
Were there puncture marks? * -- Please select one -- Yes No
Did the person require stitches? -- Please select one -- Yes No
If yes, please explain the circumstances.
Does your dog have any problems in any of the following areas? (please check all that apply)
If any items are checked, please explain.
Does your dog get frightened by novel situations or loud noises? * -- Please select one -- Yes No Not Sure
If yes, does your dog recover (start relaxing) in a few minutes or does their anxiety increase?
Does your dog live with dogs? * -- Please select one -- Yes No
Does your dog live with cats? * -- Please select one -- Yes No
Does your dog live with any other types of animals?
How does your dog get along with other resident animals?
Are there any breeds/types of dogs your dog automatically fears or dislikes? *
How does your dog generally react to other dogs? *
Has your dog ever been in an altercation with another dog(s)? * -- Please select one -- Yes No
If yes, how many altercations?
Has your dog ever bitten another dog causing broken skin or puncture wounds? * -- Please select one -- Yes No
If yes, please explain.
How does your dog react to puppies? *
Does your dog like to play with toys? *
Does your dog share its toys with other dogs? * -- Please select one -- Yes No Not Sure
Does your dog play with dogs other than those it lives with? *
Has your dog ever visited a dog park? * -- Please select one -- Yes No
How was your experience? -- Please select one -- Good Bad
If bad, please explain what made you uncomfortable.
Has your dog had any formal training? * -- Please select one -- Yes No
If yes, when and where?
What behaviors does your dog know? (ex. sit, down) *
Does your dog know any special behaviors or tricks? *
Further comments about your dog that would be helpful to us:
