NEW CLIENT FORM

General Information

Dog's Name *

Breed *If cross breed - please include full names of breeds (e.g. Pug X Jack Russell)

Colour *

Sex *Male or Female

Desexed *

Date of birth *

Microchip No. *

Owner's Name *

Home address *

Email address *

Phone number *

How did you find out about us?

Emergency Contact Information

Emergency contact name *

Emergency contact allowed to pick up your dog (Yes or No) *

Phone *

Emergency contact’s relationship to you *

Veterinary Clinic Information

Clinic Name *

Clinic Phone Number *

Clinic Address *

Health Information

If yes, please provide details

Worming Treatment is current *

YesNo

Date *

Behaviours

Does your dog willingly release objects? *

YesNo

How would you describe your dog's personality? *

How does your dog behave on a lead? *

Photos and videos

I give permission for ACT Barks and Recreation to take and publish photos or videos of my dog. I acknowledge that ACT Barks and Recreation may use these images on social media or their website. *

Yes No

Conditions of service

I will provide evidence of my dog’s desexing to ACT Barks and Recreation.

*

My dog has up to date vaccinations and I will provided a current vaccination certificate to ACT Barks and Recreation. *

My dog's worming treatment is up to date. *

My dog is in good health and is free from any illness that could be transmitted to other dogs. *

I have disclosed and discussed any prior behaviour issues regarding my dog towards any person or other dog.

*

Consent

I confirm that above information I have provided is true, complete and accurate. *

Signature

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Date

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