Gotham Vet Client Registration Form

Client & Dog Information

Owner First Name *

First

Last *

Last

Cell Phone *

Dog's Name *

We'd love to see your favorite picture of your dog. Share it here!

Maximum file size: 52.43MB

Address *

Address

City

State/Province

Zip/Postal

Email Address *

Weight/Breed/Age/Sex *

Date of Adoption/Purchase *

Adoption/Purchase Source *

Household Information (please list everyone who lives in the home - animals and humans (include ages) *

Emergency & Health Information

Primary Vet at Gotham *

Spayed/Neutered *

Yes

No

If no, why?

Current Medications *

Reason(s) for Medications *

Most Recent Vet Visit and Results *

Important Medical History Notes *

Description of Services

Payment Information and Agreement

Initial consultation, up to 90 minutes including follow up with training recommendations, prognosis, detailed client instructions/plan and within reason, email support for 4 weeks related to original consult. Additional sessions may be advised.

Rate: $340/90 min consult, $225/hr follow up sessions. $50 charge applies additional for each additional dog for single per consult/session.

PLEASE NOTE: ALL SESSIONS ARE NON-REFUNDABLE AND SUBJECT TO CANCELLATION POLICY.

Liability Waiver & Policies

Rescued By Training will endeavor to create as safe an environment as possible for the training of my dog and will offer only sound, safe, and responsible training and training instructions. However, to the extent that Rescued By Training is insured for any unintentional or negligent errors, omissions, or incorrect assertions, Rescued By Training will be responsible for any such acts or omissions, but only to the extent of such insurance. I understand the inherent risks of owning a dog, including but not limited to the risk of dog bites to myself or others, and consequently I am and will remain responsible for the actions of my dog at all times, and I hereby agree to indemnify and hold harmless Rescued By Training of any and all claims of injury, expense, costs, or damages caused by my dog. I understand that the recommendation of any other product or service is not a guarantee of my satisfaction with that product or service.

Initial *

Cancellation Policy: Cancellations within 72 hours are subject to half of fee for missed appointment. Cancellations made within 24 hours are subject to full fee for missed appointment unless filled by a standby appointment. Cancellations made outside of 24 hours will be rescheduled at the next available appointment. Multiple cancellations may result on being put on a standby list.

Initial *

Photography Policy: I understand photographs of me and/or my dog may be used in social media or other promotional materials for demonstration purposes.

I agree to the photography release statement. *

Yes

No

Initial *

Signature

This contract is validated by the signatures below in total and as approval for future services without additional written authorization.

Dog Guardian (Your Name Typed) *

Date *

Yes! I would like to receive tips and service updates via your newsletter. *

Yes, I'd love occasional helpful tips and updates!

No thanks, I'd prefer not to get tips.

Dog's Routine

Describe your dog’s daily routine. Please be sure to specify what type (kibble, wet, raw, dehydrated)/brand and how much food they eat. *

What does (Spot) do for exercise, and how often and for how long? *

What does (Spot) do when you’re gone from the house? Do you have video cameras to know for sure what (Spot) does or are you guessing? *

What kinds of toys, chews, etc. does (Spot) play with, and how often? When does he/she play with his/her toys? *

What kind of gear do you use with your dog, both for training and walking (please specify collar type (flat, martingale, prong, choke, other? and/or harness (front or back clip?) *

Training History/Reinforcers

Have you done any training with (Spot), or had he/she done any before you adopted him? Where did you do the training? Can you describe the basic approach you learned to train your dog? Did you feel you got the results you were looking for? *

What are your dog's favorite activities? *

What are your dog’s favorite foods or treats? Any food allergies? *

Client Goals

What skills would you like your dog to do? *

What activities would you like to be able to do with your dog? *

Fear or Aggression Toward Humans

Has (Spot's) mouth made contact with a person during any of the incidents? *

Yes

No

If yes, what is the worst result that has occurred?

Bite levels as defined by Dr. Ian Dunbar

Describe the incident(s) you are concerned about. *

Type "NA" if not applicable.

Location(s) where the incident(s) occurred: *

Type "NA" if not applicable.

Person/People involved: *

Type "NA" if not applicable.

Familiarity to dog *

Known to the dog

Strangers to the dog

Have you noticed anything similar about the situations or people involved across the incidents? (examples: all men, all at the front door, all while on leash, etc.) *

Type "NA" if not applicable.

Have you noticed any escalation or change in (Spot’s) behavior over time? *

Type "NA" if not applicable.

What does (Spot) do when strangers come into the home? *

Type "NA" if not applicable.

Did any or could any of the incidents have involved (Spot) protecting: *

Did any of the incidents involve (Spot) being: *

Did any of the incidents involve someone: *

Changing positions (sit to stand, stand to sit, etc.)

Up high (on a ladder, etc.)

Re-entering the room or reappearing

Partially obstructed (behind a wall, etc.)

Carrying something (large bag, backpack, groceries, etc.)

OtherOther

None

Separation Anxiety

Which of these signs of anxiety does (Spot) display in relation to begin left alone? *

Self mutilation (bloody paws, excessive licking, etc.)

House soiling

Pre-departure anxiety (shadowing, whining, pacing, circling, etc.)

Chewing or scratching around doors and windows

Excessive barking or whining

Extended or anxious greeting upon return escape artistry

Refusing food while alone (please list foods tried:)Refusing food while alone (please list foods tried:)

None of the above

Where do you leave (Spot) when you leave the house? *

When did you first notice that (Spot) was anxious when left alone?

Does (Spot) behave differently when left with another dog or with another person?

Is there any place that (Spot) is comfortable being left alone, such as in the car?

Is (Spot) crate-trained?

Where would you like to be able to leave (Spot) when you are not home, and for how long?

Anything else we missed you'd like to share?

Gotham Vet Client Registration Form

Client & Dog Information

Emergency & Health Information

Description of Services

Payment Information and Agreement

Liability Waiver & Policies

Signature

Dog's Routine

Training History/Reinforcers

Client Goals

Fear or Aggression Toward Humans

Separation Anxiety

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