Courteous Canine, Inc. Behavior Modification Intake

There should be a short block of text here describing why they have to fill out every little thing - otherwise, they'll ask.

Name:

Phone:

Mailing address:

State:

City:

Zip:

Email:

Receive our free online newsletter? : Yes No

How did you hear about Courteous Canine, Inc.?

Dog's Name:

Breed:

Color of dog:

Dog's Birthday:

Dog's Sex: Male Female

The dog is: Spayed Neutered Intact

Date of Vaccinations: (including bordatella)

Where did you get this dog?

Name of Vet you use:

Is this your first dog? Yes No

Breeds you have lived with:

Have you had previous dog training experience? Yes No

If yes, please describe:

How much time are you willing to spend a day to help modify this behavior?:

Other pets in household? Yes No

If yes, please describe name and ages:

Other humans in household? Yes No

If yes, please describe name and ages:

How is dog exercised? On Leash Off Leash Both

How long does exercise last?

Describe the exercise:

Is your dog afraid of loud noises/thunder? Yes No

Other behavior problems you are concerned about:

Dog medications:

Dog's illnesses:

Dog's Food:

What type of treats and/or toys does your dog like:

When does the dog get stiff/bark/growl or show teeth?:

How does the dog respond to:

You asking him/her to do something they do not want to:

You interrupt a desirable activity?:

Unexpected change in routine?:

Dog is unable to get something that he/she can't wants?

If you ignore dog and they want attention:

What behaviors does the dog use to communicate needs?

How does the dog communicate stress?

How does the dog communicate what he/she likes?

Liability Release

Owner (owner of dog, client of Courteous Canine, Inc., and handler of dog) agrees that Angelica Steinker and Courteous Canine, Inc. will not be liable for any damage or loss resulting from failure of the dog to respond to any cues or commands taught to the dog by Courteous Canine, Inc. or resulting from counseling and advice supplied to owners of dog. Dog's behavior now and in the future is solely the responsibility of the owners (client) of the dog. Should any behavior on the dog's part now or in the future result in damage to the property, owners, or person of some third party, owner agrees to assume full responsibility to such third party for any and all such damage, and to absolve Angelica Steinker and Courteous Canine, Inc. from any and all obligations to pay such damage to a third party. All dogs are trained or otherwise handled or cared for or if owner receives instruction by Angelica Steinker and Courteous Canine, Inc. without any liability whatsoever on Angelica Steinker and Courteous Canine, Inc. for loss, damage from disease, death, running away, theft, fire, injury to persons, other dogs or property by said dog, or other unavoidable causes. In the event of in-home training provided by Angelica Steinker and Courteous Canine, Inc. whether owners are home or not, owners agree to absolve Angelica Steinker and Courteous Canine, Inc. from any and all liability whatsoever for loss or damage to property. In the event of training provided at the location of Courteous Canine, Inc., 2601 Spring Green Drive, Lutz, FL 33549, owner agrees to absolve Angelica Steinker and Courteous Canine, Inc. from any and all liability whatsoever for loss or damage to property, or injury to dog, or owner, or handler and to hold her harmless therefor.

Date

Owner

Courteous Canine, Inc. Dog School & Doggie Gym is located in Lutz, close to Tampa, New Tampa, South Tampa, Wesley Chapel, Land O'Lakes, Odessa, Carrollwood, Lake Magdalene, Northdale, Oldsmar, Palm Harbor, Trinity, Safety Harbor, and Temple Terrace!

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