Assessment Form – Springfield Dog care

Welcome to Springfield Dogcare! Our goal is to provide a fun, safe and active environment for your pets to spend the day. Before we assign your dog to a specific daycare group we need some information from you about your pet and his/ her behaviour, it is important that your answers are honest.

Your Pets Name *

Title

Mr
Mrs
Miss

Owners Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Home Phone

Mobile Phone

Email *

Please enter your email, so we can follow up with you.

Emergency Contact *

First

Last

Emergency Contact Number

Relation to yourself

* Your emergency contact should be able to make decisions for you in the event you cannot be reached * (please do not provide the name your Vet for this)

Pet Information

Your Pets Name *

Dog Breed (Please enter) *

Dogs Age (Years)
Selected Value: 0

DOB *

Gender *
Male
Female

Dog Colour *

Microchip Number (If known)

Where did you get your Dog? *
Adopted
Breeder
Other

Any lumps or scars? *
Yes
No

Is your Dog Neutered/ Spayed? (copy) (copy) *
Yes
No

Veterinary Information

Please provide as much information as possible in this section.

Name of Veterinary Surgeon

Address of Practice
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code

Vets Phone Number (If known)

Who are you insured with?

Is your dog currently on any medication? *
Yes
No

Do you wish us to administer medication throughout the day? *
Yes
No

All dogs must have current vaccinations or up to date titre testing. All owners must provide veterinarian certification vaccines (Distemper, Hepatitis, Parainfluenza and Parvovirus. All dogs must receive the Bordetella (kennel cough) vaccination. All dogs must wear a collar with a nametag on it.

Vaccination

Vaccinations

Standard booster (DHPP)

Date the Standard Booster was Last Given? *

Vaccinations

Bordatella (Kennel Cough

Date the Bordatella was Last Given? *

Vaccinations

Bordatella (Flea/ Tick)

Date Flea/ tick Prevention was Last Given? *

You must maintain flea and worm treatments, as it is essential in this environment that your dog is well protected.

PLEASE ENSURE THAT YOU BRING YOUR DOG'S VACCINATION RECORDS WITH YOU WHEN YOU ATTEND FOR YOUR ASSESSMENT VISIT OR E- MAIL THEM IN. RECORDS WILL NEED TO BE UPDATED ANNUALLY AND SENT IN VIA E MAIL OR BROUGHT TO THE CENTRE TO BE COPIED.

Health

Has your dog ever had major surgery? If yes, is it something we should be concerned about? (Please give details) *
Yes
No

Does your dog have any pre-existing or current health conditions? *
Yes
No

Has your dog ever had a seizure? *
Yes
No

Does your dog have any allergies? *
Yes
No

Does your dog have hip dysplasia? *
Yes
No

Does your dog have any sensitive areas on his/ her body? *
Yes
No

Does your dog have any physical limitations that need special attention or that may prevent certain types of activities? *
Yes
No

Behaviour

Has your dog ever bitten someone or another dog? *
Yes
No

Has your dog ever snarled at someone or another dog? *
Yes
No

Can your dog share his/her toys with other dogs? *
Yes
No

Does your dog let you remove toys from its mouth? *
Yes
No

Has your dog ever participated in daycare before? *
Yes
No

Does your dog suffer from separation anxiety? *
Yes
No

What calms your dog down when they're stressed? *

Does your dog Bark Excessively? *
Yes
No

Is your dog anxious/frightened around noises, actions or objects? *
Yes
No

How do they sleep? (eg crated, with you, lights on/ off etc?) *

Whilst we are an open play facility dogs do sometimes need to be encouraged to take breaks and sleep. Are you happy for your dog to be crated during rest periods? *
Yes
No

Is your dog possessive over food? *
Yes
No

Drop-off/ Pick-up information

Please provide a password which should be given by any individual collecting your dog *

How did you hear about us? *

Is there anything else we should know? *
Yes
No

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