VBS Canine Behavior History

Canine History Form

The information you provide below will be used during your consultation to develop a diagnosis and plan of treatment. Please fill it out as completely as you can. All information will be held in strict confidence and will not be released to any third party without your written consent.
Please submit this form online at least 2 business days prior to your dog's appointment
Today's Date*

MonthDayYear
Your Contact Information
Name*

First NameLast Name
Preferred Pronouns
Spouse / Partner Name

First NameLast Name
Preferred Pronouns
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone Number*

Area CodePhone Number
Whose phone number is this?*
Secondary Phone Number

Area CodePhone Number
Whose phone number is this?
Additional Phone Number

Area CodePhone Number
Whose phone number is this?
E-mail*
Secondary email:
example@example.com
How best do you learn new information?

VerbalVisualBoth

Your Family Veterinarian's Contact Information
Family Veterinarian*
Hospital Name*
Hospital Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Hospital Email*
Do you authorize us to send a summary of the consultation to your family veterinarian?*

YesNoI would like to discuss this further at the consultationOther

	NR	M	B	G	SL	SN	BT	ND
Take dog’s meal away while he/she is eating
Add food to bowl while dog is eating
Take away dog's favorite toy
Pet the dog
Trim dog's nails
Lift or try to lift the dog
Grab dog by collar
Hug or kiss dog
Scold dog verbally
Restrain dog
Push on dog's back
Bathe dog
Push on dog's rump
Wash dog's face
Wake dog when sleeping

Your Family Veterinarian's Contact Information