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Dog Behavior Intake Form

Disclaimer

PAYMENT IS REQUIRED IN FULL AT THE TIME SERVICES ARE RENDERED. ACCEPTABLE FORMS OF PAYMENT ARE CASH, AMEX, VISA, MASTERCARD, DISCOVER, CARECREDIT, AND SCRATCHPAY (CHECKS WILL NOT BE ACCEPTED).

Owner:

Address:

Phone Number:

Pet's Name:

Breed:

Sex:

Age:

Color:

PLEASE MARK ALL OF THE APPROPRIATE BOXES AND FILL IN THE BLANKS TO THE BEST OF YOUR ABILITY

We may take pictures and videos as a part of your pet's appointment. Below is a consent form for use of images of your pet. When used, there will be no identifying information of the pet or yourself, such as your name. Please consent below to whichever options works best for you.

We may take pictures and videos as a part of your pet's appointment. Below is a consent form for use of images of your pet. When used, there will be no identifying information of the pet or yourself, such as your name. Please consent below to whichever options works best for you.

My pet's pictures and videos are to be used for my pet's medical record ONLY

My pet's pictures and videos can be used for my pet's medical record, textbooks, veterinary publications including journals, electronic publications, and veterinary presentations.

Do not use my pet's picture for any purpose including in his or hers medical records.

Who is your pet's primary care veterinarian?

Please list all veterinary hospitals where your pet has been seen in the past 5 years.

I am the owner(s) of the animal(s) seeking behavioral medicine treatment from Gold Coast

Center for Veterinary Care. Behavioral treatment, training and advice when properly maintained after completion can be very helpful in resolving problem behaviors in animals. Because each pet is an individual, no guarantee or assurance can be made as to the results that may be obtained. Animal behavior including aggression is unpredictable and will remain unpredictable after its treatment. Gold Coast Center for Veterinary Care cannot promise that the animal's behavior service treatment, training or advice will completely eliminate the animals potential danger to persons or completely control the animals aggressiveness. Animals should be closely supervised particularly around children and infants and should be controlled at all times including conformance with local ordinance and "leash laws".

I am bringing my pet to this appointment with a full knowledge of these risks and understand and accept the liability that is inherent in owning a pet who has shown aggressive behavior.

I understand that all fees are to be paid tat the time of service and accept full responsibility for the charges incurred in the treatment of my pet.

Telehealth appointments may be recorded for internal training only.