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805.685.6068

805.456.0454

info@dioji.com or contact us

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Owner Information

Owner's Name:*

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Who should we call to pick up your dog if we cannot reach you?

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In addition to yourself and the individuals listed above, name all who are authorized to pick up your dog:

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Dog Information

Your Dog's Name:*

Breed:*

Sex:*

Male Female

Birthdate:*

Weight:*

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Veterinarian:*

Is your dog spayed/neutered?*

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Has your dog visited dog parks?*

Yes No

Has your dog been to Day Care?*

Yes No

Have you boarded your dog?*

Yes No

Does your dog like to play with other dogs?*

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Would you like your dog to swim in our pool?*

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Do you use any flea or tick products?*

Yes No

Does your dog have any allergies?* Yes No
If yes, please list:

Does your dog have any ongoing medical issues or past injuries?* Yes No
If yes, please list and describe:

Does your dog have any sensitive areas?* Yes No
If yes, please list and describe how he/she responds to being touched in these areas:

How does your dog respond if another dog attempts to play with his/her toy?*

How does your dog respond if you take his/her toy away?*

Does your dog have any specific fears or dislikes?* Yes No
If yes, please list and describe how he/she responds to these:

Has your dog ever been in a dog fight or snapped at or bitten someone?* Yes No
If yes, please describe:

How did you hear about us?*

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