KPDT: Client Intake for Aggression Cases "*" indicates required fields Step 1 of 5 20% Your Email* Name First Last Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Spouse/Partner Phone # and Email Address (If Applicable) Kids in Household? If yes, please list names and ages.Kids name and Age (01)Kids name and Age (02)Kids name and Age (03)Household Staff? If yes, please list name(s) and a brief description of interactions/responsibilities related to the dog(s).Name and Description (01)Name and Description (02) Add Remove Tell Us About Your DogDog's Name ** Dog's Breed ** Gender* Male Female Dog's Age (please include actual birthday if known)* Is your dog neutered/spayed? ** Yes No At what age was your dog neutered/spayed? Where did your dog come from? ** Breeder Pet Store Rescue/Foster Other Are there other pets in your home? (If yes, please list specifics including species/breed, name, age, neuter/spay status)*Please Describe Have you had dogs before?* Yes No Health InformationWho is your Vet? (Please include primary Dr.'s name along with practice/clinic name, address, and phone #)*Any health concerns? (past or present)* Is your dog currently taking any medication? (If yes, please list medication name and dosage)*What are you feeding your dog? (Please list brand, amount, feeding schedule)*Any Food Allergies? (If yes, please specify) ** Has your dog's thyroid been checked? If so, when? Have your dog's joints been checked for pain? If so, when? Have your dog's anal glands been checked? If so, when? Have your dog's teeth been checked? If so, when? When was your dog's last full wellness check up? In-Home Setup/Exercise RoutineDog's Sleep Location* Dog's response when strangers enter the home ** What is your dog's walk schedule?* What walking equipment do you use? ** Do you go to the dog park/have playdates?* Do you have a dog walker?* Yes No If you have a dog walker, please provide their details (name, company name, email, phone #)Does your dog go to daycare? If so, which daycare (name, address, phone #) and how often? Behavioral InformationHow many times has your dog growled at people? How many times has your dog growled at other dogs? How many times has your dog bitten a person? How many times has your dog bitten another dog? How severe was/were the bite(s)? (graze, puncture, broken skin?) What was the person/other dog doing when your dog bit them? What was their body position; over them, reaching for them, or something else?What age was your dog when the issue(s) started? Additional Notes CAPTCHA Δ
