Client Questionnaire Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.OWNER INFORMATION Name *FirstLastEmail *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Please list all human family members and their age(s). *Please let us know how you heard about us. *DOG INFORMATIONWhat is your dog(s) name? *Is this your first dog as an adult? *YesNoGender of your dog? *MaleFemaleWhat breed is your dog? *What is your dog's current age? *Where did you obtain your dog? *Please list breeder, rescue or shelterWhat age did your dog join your family? *Is your dog spayed/neutered? *YesNoWhat age was your dog spayed/neutered? *Reason you chose your dog: *TELL US ABOUT YOUR DOGIs your dog house trained? *YesNoReason you are seeking training: *How long has this been a problem? *Has it become better, worse or stayed the same? *BetterWorseStayed the sameWhat have you been doing to address this/these issue(s)? *What have you tried that didn't work or made the problem worse? *In what type of training program are you interested? *Private In-home 1:1 trainingBoard & TrainGroup Class (we do not currently have group classes scheduled)I don't know what is right for meWhere is your dog when left alone? * injury I and How often is he/she left alone? *For how long is he left alone each day? *When left alone, what does your dog do?BarksChews Furniture/CrateDestructiveSoil in the houseWhinesPlay/chews on toysScratches Doors/CrateSleepUnsureHow much daily exercise does your dog get each day? *List the amount per day and/or per week, and what kind of exerciseHas your dog had training in the past?Yes, in a group classYes, in private lessonsYes, in board & trainSelf trainedNo, but I'm excited to get startedWhere did you receive previous training? *How was your previous experience? *What training methods have been used to train your dog? *Food based trainingToy based trainingAffection/praise based trainingVerbal correction (saying No!, etc)Slip/Choke Collar trainingProng/Pinch Collar trainingRemote/E-collar trainingElectric Fence trainingOther not listedNonePlease check all that applyWhat skills does your dog know? *SitDownStayLeave itTake itOut or Drop itLoose Lease WalkingCome When CalledTouchLook/Eye contact with handlerTricks (shake, roll over, etc)Go to your...(bed, crate, etc)Other, not listedPlease check all that applyHas your dog ever bitten anyone? *Please list if your dog has ever bitten a person or animal, and include as many details as you can remember (severity of bite, location on body of bite, what happened before bite happened, if any medical attention was needed, etc).DOG HEALTH INFORMATIONYour dog's veterinary/clinic office & vet name: *Date of your last vet visit: *Date of your last full physical your dog received: *Please list any diseases, conditions, surgeries, etc. your dog is currently diagnosed or experienced: *Please list any medications your dog currently is taking. *Please list current vaccinations for your dog: *What brand food is your dog currently eating, how much per meal and how often do you feed per day? *WAIVERS & AGREEMENTSI understand that dog training and behavior modification is not without risk to myself, members of my family, guests or my dog or other pets. I hereby waive my rights to any claim and release Southern Dogworks, it's instructors and agents from any and all liability of any nature, for injury or damage which I or my dog may suffer, including specifically, but not limited to, any injury or damage resulting from the action of any dog, and I expressly assume the risk of any such damage or injury while attending any training session, function or event wherever the activity is taking place. In consideration of and as inducement towards the acceptance of my enrollment in lessons, I hereby agree to indemnify and hold harmless Southern Dogworks, its instructors and/or agents from any and all claims, or claims by me, any member of my family or any other person accompanying me to any other person accompanying me to any training session wherever they may be located arising out of any action by any dog, including my own, including but not limited to the responsibility for all damages, expenses and legal fees. I further indemnify and agree to hold harmless Southern Dogworks, it's instructors and/or agents from any and all claims, or claims by any third party at any training session wherever they may be located arising out of any action by any dog, including my own, including but not limited to the responsibility for damages, expenses and legal fees. I have read, and by completing this from and checking the box below, agree to abide by the aforementioned Waiver, Assumption of Risk and Agreement to Hold Harmless, and the Guidelines of Southern Dogworks. *I have read and agree to the above statementFees are due in full, unless otherwise agreed upon by Southern Dogworks owner, prior to any Board & Train Program. A Board and Train Contract, Boarding Information Form and Vaccination records are also a part of the paperwork to be completed prior to any Board and Train Program. Titers may be considered in replacement of vaccinations. Bordatella and clear fecal float are also required before any Board and Train Program. Fees are listed on www.southerndogworks.com, and subject to change at anytime without notice. *I have read and agree to the above statementFees are due in full, unless otherwise agreed upon by Southern Dogworks owner, after the completion of the first session for any private in-home training package, private session and/or virtual lesson. Client will be billed at normal appointment fee for any "no shows" or appointment canceled with fewer than 24 hours notice. Any returned checks are subject to a $40 bank fee and $20 late fee. Southern Dogworks accepts cash, personal checks, credit/debit through Paypal. *I have read and agree to the above statementI hereby assign and grant to Southern Dogworks the right and permission to use, reproduce, distribute and publish the photograph(s), film(s), videotape(s), audio and video recording(s), electronic representation(s) and/or sound recording(s) made of me and/or my dog(s) at anytime during the training, boarding and/or board/training of my dog(s) by Southern Dogworks, and I hereby release Southern Dogworks from any and all liability resulting from such use, reproduction, distribution and publication. I hereby authorize the reproduction, sale, distribution, copyright, exhibit, broadcast, and/or electronic storage of any and all such photograph(s), film(s), videotape(s), audio and video recording(s), electronic representation(s) and/or sound recording(s) without limitation at the discretion of Southern Dogworks and I specifically waive any and all right to any compensation for any of the foregoing. *I have read and agree to the above statementSignature of Acceptance: *Please type your name as entered above on this form,SUBMIT
