Jeff Stallings, CPDT-KA Client Intake and Release

Veterinarian Phone Number

Is your dog spayed/neutered?

Yes No

Your dog's current age

Age at which you adopted

Where did you acquire your dog? (Breeder, pet shop, rescue, shelter, etc.)

Has your dog ever bitten another dog?

Yes No

Has your dog ever bitten a human?

Yes No

If Yes to either of the above, please explain:

Does your dog resource guard toys, food, space, people or anything else from:

Other dogs Humans

If your dog does guard from other dogs and/or humans, please elaborate:

Does your dog exhibit separation anxiety or isolation distress?

Yes No

If your dog does exhibit separation anxiety or isolation distress, please elaborate:

Does your dog pull on leashed walks?

Yes No

Is your dog leash reactive/aggressive towards other dogs or people?

Yes No

If your dog is leash reactive to dogs or to humans, or is reactive/aggressive to dogs or humans in other settings, please elaborate:

What is your dog wearing on leashed walks (collar, harness, etc.) Please specify type and brand.

How would you describe your dog's leash skills?

What training have you done with your dog? What commands does s/he know and how well does s/he perform them?

Please describe any behavior problems or concerns with your dog

WAIVER OF LIABILITY AND INFORMED CONSENT RELEASE
Please read and check the box if you agree to these terms.

The owner agrees that Jeff Stallings / Better Nature Dog Training, any referring organization, other participants, representatives, or assistants will not be liable for any damages or loss resulting from counseling, instruction, advice or recommendations supplied to the dog’s owner.

The dog’s behavior now and in the future is solely the responsibility of the owner of the dog. Should any behavior on the dog’s part now or in the future result in damages to property, owner, or persons of some third party, the owner agrees to assume the full responsibility and liability to such third party for any and all such damages and to absolve Jeff Stallings / Better Nature Dog Training, any referring organization, other participants, representatives, or assistants from any and all obligations to pay such damages to a third party.

Owner agrees that any dog trained or otherwise handled by Jeff Stallings / Better Nature Dog Training, any referring organization, other participants, representatives, or assistants are not liable for loss or damage from disease, death, running away, theft, fire, injury to persons, other dogs, other animals or property by said dog.

Owner agrees to follow all state, county, and city leash laws and all state, county, and city pet ordinances.

I have read this Liability and Informed Consent Release and agree to all terms and conditions herein.

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