Name*

Return Customer?

Address*

City*

State* State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AA AE AP AS FM GU MP MH PR PW VI

Zip Code*

Home Phone*

Work/Cell Phone

Email Address*

Breed(s)*

Age*

Color*

Gender Male Female

Spayed or neutered? Yes No

Current on vaccines? Yes No

Years/Months of ownership:

How did you obtain your dog? Please Choose Breeder Shelter or Rescue Organization Rescued as stray Friends or other 3rd party Other

How many hours a day is the dog alone?

Where does the dog stay? Please Choose Outside all the time Inside all the time Outside when we're not home In and Out access (doggie door)

Housebreaking: Does your dog have accidents indoors? Yes No Sometimes

Does your dog pull on the leash? Yes No Sometimes

Does your dog bark excessively? Yes No Sometimes

Does your dog growl at or show other signs of aggression towards people? Yes No Sometimes

Does your dog growl at or show other signs of aggression towards other dogs? Yes No Sometimes

Does your dog growl at or show other signs of aggression towards you or another family member? Yes No Sometimes

Has your dog ever bitten anyone? Yes No Sometimes

Does your dog shy away from people? Yes No Sometimes

Does your dog jump on you and/or other people? Yes No Sometimes

Is your dog possessive of food or toys? Yes No Sometimes

Does your dog dig, chew, steal food or run away? Yes No Sometimes

Has your dog had any previous training? (If no skip to Additional Information) Yes No

If yes, what type of training? Self Taught Puppy Class (when the dog was younger) Group Class One-on-One Private Training In Kennel Training (the dog was boarded and trained at the trainer's facility)

If One-on-One Private Training, how many sessions? N/A 1-3 3-6 More than 6

If Kennel Training, how many weeks? N/A 2 3 4-6 More than 6

Does your dog sometimes not respond to a command? Yes No Sometimes

What type of training collar do you use? Flat/Nylon Collar Halti or Gentle Leader Choke Chain Prong/Pinch Collar Other

What is the best time of day to reach you? (We do not make calls after 7pm)

Which training facility would you prefer? Please Choose Tarzana West L.A.

How did you hear about us? Please Choose Referred by friend or private party Online Search New Leash On Life Brochure/Postcard Bobby's Business Card Jennifer's Business Card Sharon's Business Card Nuts for Mutts Other

Is there any other information you'd like us to know?