Murphy Road Animal Hospital / Doggie Daycare Application Form

Form - Doggie Daycare Application Form

Name (required)
First Name (required)	Last Name (required)

Address (required)
Street Address (required)


City (required)	State/Province (required)	Zip/Postal Code (required)
,

Phone (required)
Phone Type	Phone Number (required)

E-Mail Address (required) :

Dog's Information

Dog's Name (required)

Breed (required)

Age (required)

Weight (required)

Sex (required)
M
F

Age when Spayed/Neutered (required)

Age when acquired? (required)

Where did you obtain your dog? (required)

Is your dog: (Please check all that apply) (required)
Allowed to run free in the home:Supervised/Unsupervised
Allowed to run free in fenced yard: Supervised/Unsupervised
Allowed leashed walks only
Allowed outside and unleashed but supervised

Has your dog jumped over fence in yard? (required)
yes
no

If yes, how high?

Has your dog:(Please check all that apply) (required)
Ever been on agility equipment?
Shared his/ her food or toys with any other animals?
Ever growled or snapped at anyone taking food or toys away?

If yes, please explain

Has your dog ever bitten a person or another dog? (required)
yes
no

If yes, please explain

Does your dog prefer to play with (required)
Male dogs
Female dogs
Both

Is your dog possesive of any toys, food or objects? If yes please explain. (required)

How does your dog react when strangers approach your home, yard, or out in public? (required)

Is your dog afraid of any other types of dogs? (required)
Yes
No

If yes, please explain

Does your dog play off leash with other dogs? (required)
yes
no

How does your dog react to puppies? (required)

What is your dog's training history? Check all that apply.
Group class basic
Group class advanced
private training classes
Trained yourself
puppy training sessions
Obedience titles/awards
Puppy kindergarten
Agility
no training

Other

Is your dog sensitive about any parts of his/her body? (required)
Tail
Paws
Hindquarters
Nails clipped
Being brushed
none

If yes, please explain

Hip problems? (required)
yes
no

If yes, what restrictions need to be placed on your dog's activities or movements?

Are there any physical problems or disabilities which may affect them in daycare? (required)
yes
no

If yes please explain

Please list any other issue(s) you wish to address or feel you should inform us of.

How serious of a problem do you consider this to be?
Very serious
Serious
Not serious

How exercise is your dog currently getting? (required)

What is the main reason you have chosen daycare for your dog? (required)

Health and Temperament Agreement

I hereby certify that my dog(s) (required)
are in good health
have not been ill with any communicable diseases in the last 30 days
has not harmed or shown aggressive behaviour toward any person or any other dog.

VACCINATION DATES:

DHPP(Distemper,Hepatitis,Parainfluenza,Parvovirus)

Given by:

RABIES

Given by:

BORDATELLA

Given by:

FECAL SAMPLE

Tested by:

ALLERGIES:

Has your dog had fleas or ticks in the last year? Please describe (required)

Is your dog on flea and/or tick prevention? (required)
yes
no

If yes, what kind?

Is your dog on heartworm pills? (required)
yes
no

If yes, what kind?

Signature of Owner (required)

Date (required)

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