Fill out the form below.

Please Note: All fields marked with * are required. If you have any questions, please feel free to contact us.

Client Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Home Phone Number *

Cell Phone Number

Veterinarian's Name *

Clinic Phone Number

Veterinary Clinic Name *

Veterinary Clinic Email *

Pet Information

Pet's Name *

Date of Birth or Estimated Age *

Breed *

Colour *

Sex *

Male
Female

Spay/Neutered *

Age at Adoption *

Adopted From *

Please list all family members, including age, and their level of interaction with your dog: *

Please list all pets at home, including age, breed, sex, and spayed/neutered *

Please describe your main concerns about your dog’s behaviour *

Please describe any treatment you have tried before *

What are your long term expectations with regards to your dog's behaviour? *

Please list other people that your dog may interact with *

Please list any health concerns your dog may have and any medication you administer *

How long does it take your dog to settle down once he/she reacts to any of the above situations? *

Have you considered removing your dog from the home if the problem cannot be improved? *

concerns and may

We ask that this questionnaire kindly be completed and returned at least SEVEN days before your consultation. These questionnaires provide us with much of the background information we may require to make a diagnosis and develop a treatment plan tailored to your specific needs.

These are questions developed by Dr. Sagi Denenberg of North Toronto Veterinary Behaviour Specialty Clinic.

Questionnaire Form

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Pet Information

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