Online Application Form

Location

Dioji Membership is valid at both the Goleta and Santa Barbara locations. Which location would you like to visit for your first FREE day of play? *

Goleta Santa Barbara

Owner Information
Owner's Name:*
Email Address:*
Home Address:*
City:*
State:*
Zip:*
Home Phone:* () -
Work Phone: () -
Cell Phone: () -
   

Who should we call to pick up your dog if we cannot reach you?
   
Name 1:*
Phone:* () -
Name 2:
Phone: () -
   

In addition to yourself and the individuals listed above, name all who are authorized to pick up your dog:
   
Name 1:*
Name 2:
Name 3:
   

Dog Information
Your Dog's Name:*
Breed:*
Sex:* Male Female
Birthdate:*
Weight:* Lbs
Veterinarian:*
   
   
Is your dog spayed/neutered?* Yes No
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?* Yes No
Would you like your dog to swim in our pool?* Yes No
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?*
Web Search Vet Free Day Pass
Drive-by Newspaper Ad
Article TV Commercial
Friend
Other
 

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