Registration Form

* indicates required field


Owner Information

First Name:*
Last Name:*
Address:*
City:*
State:*
Zip:*
Home Phone:*
Work Phone:
Cell Phone:
Email:*

Services Interested In (please choose one or more)*

How did you hear about us?*

Emergency Contact Information
Spouse/Significant Other

First Name:
Last Name:
Phone:

Someone Outside Immediate Family

First Name:*
Last Name:*
Phone:*
Relationship:*

Veterinarian Information

Hospital:*
Doctor's Name:
Address:
City:
State:
Zip:
Phone:

Dog Information

Name:*
Primary Breed:*
Color:*
Sex:*
Neutered/Spayed:*
Birth Date:*
Month: Date: Year: If exact birth date not known, please enter an approximate date.
Weight (in lbs.):*
Where did you get your dog?*
How long have you had your dog?*

Other Household Pets

Pet 1

Species
Sex
Neutered/Spayed
Age
 

Pet 2

Species
Sex
Neutered/Spayed
Age
 

Pet 3

Species
Sex
Neutered/Spayed
Age
 

Medical History

We will need a copy of your most recent veterinarian vaccination records showing proof of Rabies vaccine, DHLPP (Distemper/Parvo) vaccine, Bordetella (Canine Cough) vaccine and a Fecal exam. You or your vet can fax this information to us at 914-930-8132 or you can upload it now by clicking below.
(Note: Some devices may not allow you to select an attachment to upload.)

Type/Frequency of Flea/Tick preventive:*

Please list below any current or past medical problems/treatments or allergies:

Behavior
Has your dog ever ...

Been to obedience class?*
Been socialized to other dogs?*
Jumped a fence?*
Had to share food/water/toys with other dogs?*
Growled at a person?*
Growled at another dog?*
Bitten a person?*
Bitten another dog?*

Other Information

What do you hope to achieve for you and your dog by utilizing our services?*

Is there anything else you would like to share with us about your dog?

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