Date _______________

Dog's name _______________________ Age _____ Sex______ Breed ____________________

Is he/she spayed/neutered? Y / N


Owner's name, address, phone number ____________________________________________


Names and numbers we can call for an emergency


What is the name and phone number of your dogs vet?


What is your dogs favorite game or toys? ___________________________________________

Would you like your dog to swim in our pond if appropriate? Y / N

How does your dog act around other dogs - aggressive, skittish, confident, playful, etc.


Has your dog ever been around a large of number of dogs? Y / N

If so, how did he/she react? ______________________________________________________

Has your dog ever been in a dogfight? Y / N

Has your dog ever growled at or bit a person? Y / N

How does your dog behave around small children? ___________________________________

Does your dog like to jump fences? Y / N

Does your dog have arthritis, hip dysplasia or any other health problems? Y / N

If so, please explain. ___________________________________________________________


Is your dog on any medications? Y / N

Type? ____________________________________________

Is your dog on a special diet? Y / N

If so, what kind? ____________________________________

How much do you feed your dog? ________________________________________________

Any canned food? ___________________________________

Has your dog been boarded before ? Y / N

If so, how did they react? _____________________________


I, _______________________________________________, hereby claim that all the above


information is correct and all inclusive regarding my dog's health and behavior history.


Country Livin' Dog Daycare & Kennels LLC
30918 Peterson Rd.
Philomath, OR
(541) 929-3356
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