05/15 info sheet

Dog History Form
Please read and answer each question thoroughly
(questions marked with * are required)
Appointment Date*

MonthDayYear
Appointment time:*

:HourMinutesAM/PM Option
Human Info:
Full Name*

First NameLast Name
Cell phone number*
Do you want to receive appointment reminders?*

YesNo
How do you prefer to receive appointment reminders?

TextEmailBoth
Home phone number
Address*

Street Address

Apt/Unit #

City

Zip Code
E-mail*
Occupation
Names and ages of other humans in the household:*
How did you hear about Animal Attraction Unlimited?
What search words would you use to find a dog trainer from the internet?
Dog Info:
Dog's name*
Date of Birth (best guess)*

MonthDayYear
Breed (best guess)*
Gender*

MaleFemale
Spayed/Neutered?*

YesNo, not planning toNot yet but planning to
If yes, at what age?
Where did you get your dog?*
How long have you had your dog?*
Name of veterinarian*
When was the last time your dog saw a veterinarian?*
If less than 6 months ago what was the reason for your visit & the outcome?
Is your dog on any flea or heartworm medications? If so, please list:
Does your dog have any medical issues, allergies or physical limitations? If so, please list:
Has your dog had previous training?*

YesNoUnknownSeems to have had training
If yes, at what age?
Type of training

PrivateGroup ClassesI did my own trainingUnknown
Name of trainer(s)
What have you taught your dog to do?*
Is this your first dog?*

YesNo
If this is not your first dog how long has it been since you've lived with a dog?

0 - 5 years5 - 10 yearsMore than 10 yearsI currently have another dog
Is your dog crate trained?*

YesNoIn processUnknown
Where does your dog sleep?*
Is your dog allowed on the furniture?*

No, neverYes, all furnitureSometimesOne specific piece of furnitureOnly when invitedOther
Do you have a dog door?

YesNo
Percent of time your dog spends indoors*
Percent of time dog spends indoors?*
Where does your dog stay when no one is home?
Does your dog go to:*

DaycareDog parks
Does your dog go to:

DaycareDog parks
If yes to either, how often?
Please supply name of daycare if applicable
What brand / type of food does your dog eat?
How many times a day do you feed your dog?*

OneTwoThreeThe food is left out all day
Does your dog finish all the food at the time you present it?*

YesAlmost always50 / 50Rarely
Do you ever add things to the food to get your dog to eat? If so, please describe:*
Does your dog play with toys?*

Yes, oftenSometimesNo, never
What types of games do you play with your dog? (check all that apply)*

FetchTug o'War with youWrestle / rough housingChase (I chase the dog)Chase (dog chases me)Slappy head (hands moving around dog's face/head)Other
What type of collar do you use for walking / training?*

Flat / BuckleHead HalterNo Pull HarnessProng / PinchChokeBody HarnessMartingaleOther
What type of leash do you walk with?*

LeatherNylonRetractableOther
Describe in detail your dog's behavior when someone they've never met comes into your home.*
What kind of training does your dog need?*

Basic obedienceBehavior issueOther
If a "behavior issue" or "other" please describe
How long ago did you first notice these issues?
What have you done to change this behavior?
Did the problem become...

BetterWorseStayed the same
Has your dog ever bitten a person?*

YesNo
Has your dog ever bitten another animal?*

YesNo
If yes to either, was the skin broken?*

YesNoUnknownn/a
If skin was broken was medical care sought?

YesNoUnknownn/a
If your dog has bitten either a person or animal, describe the incident in detail:
List 3 things you want your dog to learn:*
Please list the things you like about your dog:
What are your dog's favorite things?*
What are your dog's least favorite things?*
How much time do you spend training your dog, and what do you do?
Please list other animals in the house*
Is there anything else you want me to know about your dog or situation?
I always take a photo of your dog for your file in my database. However, sometimes I like to share photos on social media as well. I NEVER use your personal information, only the dog's name. Please indicate if it's okay with you that I share your dog's photo and on which medium. Thank you! *

FaceBookInstagramTwitterNone
If you listen to podcasts please tell me which podcast player you use.
Stitcher, Podbean, Soundcloud, etc...
Terms of service

By submitting this form I confirm that I am at least 18 years of age and agree that all the information provided is true and correct to the best of my knowledge. I also acknowledge that the training rates have been provided to me and agree to the non-refundable deposit of $75.00 to reserve my appointment time and date. The balance of the first session payment is due at the end of the first session. I understand that if I need to reschedule my appointment, a minimum of 48-hours' advanced notice must be provided to Laura Bourhenne / AAU VIA EMAIL ONLY, DO NOT TEXT; if I do not notify Laura Bourhenne / AAU within this time period, the $75.00 deposit will be forfeited. Pre-paid packages: when less than 48-hours' notice of cancellation of a session is given, one (1) session of the package will be forfeited per incident. No refunds or exchanges.
Terms of service:

By submitting this form, I (“Client”) confirm that Client is at least 18 years of age and agrees that all the information provided by or on behalf of Client is true and correct to the best of Client’s knowledge. Client acknowledges that Laura Bourhenne/Animal Attraction Unlimited (“Consultant”) has provided Client with the training rates, and Client agrees to the non-refundable deposit of $95.00 (the “Deposit”) to reserve an appointment time and date. The balance of the first session payment (after credit for the Deposit) is due at the end of the first session. Client understands that a minimum of 48-hours' advanced notice must be provided in order to postpone any session or appointment. Such notice must be provided VIA EMAIL OR TELEPHONE CALL ONLY. DO NOT TEXT. Failure to notify Consultant within said 48-hour time period shall result in forfeiture of the Deposit. Additionally, for any pre-paid packages (where a series of more than one session is paid in a lump sum at a discounted rate), if less than 48 hours’ notice of cancellation of a session is given, one (1) session of the package will be forfeited per incident. No refunds or exchanges will be provided.
Liability release

I forever waive and release AAU, Laura Bourhenne, her family, heirs, acquaintances and agents, or any person acting on her behalf or at her request from any and all liability and/or demands which I, for myself, my heirs, executors, personal and/or legal representatives or assigns may have or hereafter have, at any time, for injury or damage to myself, my dog(s), my property and/or my guests, their dogs and property, and assume all risks thereof.
Client hereby consents to Client’s pet(s) being the subject of photographs and/or audiovisual recordings and authorize Consultant to use and exploit the same for promotional, advertising and/or educational purposes, as photographs,transparencies, motion pictures, television, video or other similar media. Client hereby releases Consultant from any and all claims for damages for libel,slander, invasion of privacy or any other claim based on use of the above-described material(s), and any such use of said materials shall be done without liability or obligation to Client, and without any form of compensation to Client.*

YesNo
Waiver and Release:

Client acknowledges and agrees that (i) Client has been informed and understands that there is always some unavoidable risk of injury involved when working with or otherwise taking possession of animals, especially animals with behavioral issues, (ii) dogs can be inherently difficult to control, and not all dogs will be under control at all times resulting in the possibility of injury to Client, Client’s dog(s), family members, third parties, and/or other dogs/animals, and (iii) Client has had full opportunity to discuss all concerns about the foregoing risks (and the risks described below) with Consultant and any such additional experts or consultants of Client’s own choosing.

Client and his/her dog(s) participating in or receiving any services from Consultant is done entirely at Client’s own risk. Client is voluntarily participating in and accepting all services and the use of any locations (indoor and outdoor), facilities and premises where Consultant may provide services, and Client accepts and assumes, without reservation, all risks (i) associated with participation in and receipt of any services from Consultant, including, without limitation, the risks of any injuries to Client, his/her dog(s), family members, third parties, and/or other dogs or animals that may attend or otherwise be present in any areas of any services, (ii) that Client’s dog(s) may cause injury to other persons and/or dogs, or damage to property, involved in any such services, (iii) that saliva, water, food, and/or other debris may be present in training areas (which may present slippery or otherwise unsafe conditions), and (iv) that Client’s dog(s), while in Consultant's care, may be exposed to other animals and conditions (at parks, trails, the beach, etc.), which always present a risk of injury and/or sickness from accident, fight, exposure to pathogens, disease or infection (regardless of vaccination), toxins, and/or other harmful materials/conditions.

Client acknowledges that client has carefully read the waiver and release contained in this contract and fully understands that it is a waiver and release of liability. As lawful consideration for participating in and/or receiving any services from Consultant, and to the fullest extent permitted by law, Client, for Client and Client’s heirs, executors, administrators, legal representatives, successors and assigns (the “Releasing Party”), hereby waive, release, discharge and agree not to sue and to indemnify, defend and hold harmless Consultant, and her managers, contractors, agents, employees, affiliates and related entities, and representatives (the “Released Party”) from any and all injuries (including illness and/or death), losses, claims and damages to any animal(s) (including Client’s dog(s) and any other animals), person or persons, or property, of any nature whatsoever, including claims arising from the Released Party’s own negligence, and all costs associated therewith, including attorney’s fees, court costs and consultant fees, arising from or relating to your participation in or receipt of any services from Consultant and/or otherwise caused by or relating to Client’s dog(s). Should the Releasing Party assert a claim to the contrary to what Client has agreed to in this Form, the claiming party shall be liable for all expenses (including attorney’s fees, court costs and consultant fees) incurred by both the Releasing Party and the Released Party. If any portion of this Form shall be deemed by a Court of competent jurisdiction to be invalid, the invalid portion shall be deemed severed, and the remaining terms and conditions herein shall remain in full force and effect.
This agreement and the forms submitted constitute the entire agreement of the parties hereto with respect to the subject matter contained herein, and supersede all prior and contemporaneous understandings and agreements, both written and oral, with respect to such subject matter. In the event of any conflict between this agreement and any other forms/agreements submitted by Client, the terms contained in this agreement shall control. This agreement shall be governed by and construed in accordance with California law without giving effect to any choice or conflict of law provision or rule. Any legal suit, action or proceeding arising out of this agreement or the services provided by Consultant shall only be instituted in the federal courts of the United States of America or the courts in State of California, in each case located in the city of Los Angeles and county of Los Angeles. This agreement may only be modified by a writing signed by Client and Consultant. Consultant’s failure to exercise, or delay in exercising, any right, remedy, power or privilege under this agreement shall not operate or be construed as a waiver thereof; nor shall any single or partial exercise of any right, remedy, power or privilege hereunder preclude any other or further exercise thereof or the exercise of any other right, remedy, power or privilege.
Full Name*

First NameLast Name
Signature

Clear
Date*

MonthDayYear
Thank you for taking the time to fill out this questionnaire, it is very important to the treatment of your dog's issues. I look forward to meeting you.

Below is the deposit payment form.

Payment*

Non-refundable deposit$95.00

Total $0.00

Credit Card

Should be Empty:

Dog History Form

Human Info:

Dog Info:

Thank you for taking the time to fill out this questionnaire, it is very important to the treatment of your dog's issues. I look forward to meeting you.

Credit Card