DarnFar Ranch

Please provide the following contact information:

First Name
Last Name
Alternate Contact's Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Phone
Work/Cell Phone
Emergency Contact's Phone
E-mail

Please describe your dog:

Name
Age	specify months or years
Sex	Male Female
Breed
Color

Spayed / Neutered?

Yes
No

Please provide the following information about your Veterinarian:

Vet's Name
Vet's Office/Business Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Vet's Phone

Date Rabies vaccine expires:

-- mm/dd/yy

Date Distemper/Parvo (DHLPP) expires:

-- mm/dd/yy

Date Bordetella Expires:

-- mm/dd/yy

Type/brand of flea preventative used:

Date last administered Flea Preventative:

-- mm/dd/yy

Type of Heartworm preventative used:

Date last administered Heartworm meds

-- mm/dd/yy

List any current medical conditions this dog has:

Describe any medicines or treatments this dog will require while in training:

List the dog's current food:

How often does this dog eat?

Once per day
Twice per day

Select any of these problem areas that apply to this dog:

Mouthing a person's hand or arm      Nipping                                    Biting                                            Aggressive biting                       
Scratching people                           Jumping on people                    Jumping on tables or furniture          Jumping at fences, gates, doors         
Barking                                          Pulling when walking on lead      Aggression towards cats                Chasing animals                         
Chasing vehicles                             Chasing people                         Hyper-activity                                 Chewing                                 
Does not come when called             Runs away when called             Growls at other dogs                       Attacks other dogs                      
Growls at people                             Attacks people                            

Describe any other problem areas that this dog has.

What training duration would you prefer?

Two weeks - Basic Three weeks - Extended Three weeks - Aggressive/Anti Social Four weeks - Aggressive / AntiSocial

Are you interested in a Custom DVD of your dog's training?

Yes
No

Are you interested in a Bath and Nail trim on the day of pick up?

Yes
No

What would be your preference for a drop-off date (please note, we will get back to you whether we have an opening at your desired time)

Please provide any additional details that may be important for us to know.