About You

Your Full Name:

Preferred Name, if different:

Email address:

Phone Number:

Preferred Method of Contact:

Phone Text Email

Preferred Time to be contacted:

Morning Afternoon Evening

About Your Dogs

Dog’s Name:

Age or date of birth:

Breed or Breed Mix:

Sex

Female Male

Is your dog:

Spayed/Neutered Not Spayed/Neutered Prefer not to say

Approximate Weight:

How long has your dog been in your care?

About Your Location, Services and Schedule

Service Address or ZIP Code:

Medical & Recovery Support

Medication Administration & Health Monitoring Chronic Condition Support Post-Surgical & Recovery Care Nutrition & Feeding Support

Advanced & End-of-Life Care

Comfort-Focused Care Complex & Advanced Care Complex & Advanced Care

Guardian Support

When are you hoping to begin services?

How often do you anticipate needing care?

Your Dog’s Current Needs

Please tell us about your dog's current health, mobility, or age-related needs. For example: arthritis, mobility limitations, heart or respiratory conditions, seizures, diabetes, vision or hearing loss, cognitive changes, medication needs, recovery from surgery, or other concerns.

Does your dog currently require medication or other routine health support?

Yes No Not Sure

If yes: please briefly describe the type of medication support needed (do not list medications at this time).

Your Dog’sMobility

How does your dog currently move around?

Others

Does your dog need assistance with any of the following? Select all that apply:

Other:

YourDog’s Comfort andSafety

Your dog's wellbeing is our number one priority. We need to know about your senior dog's experience of pain, cognitive changes, fear, sensory loss, or discomfort that af ects behavior.

How does your dog generally respond to new people?

Other:

Has your dog ever shown behavior that a caregiver should know about?

Other:

Please describe any behavior, handling preferences, triggers, or approaches that help your dog feel safe and comfortable.

WhatMattersMosttoYou?

What would you most like us to know about your dog? Tell us about your dog's personality, favorite activities, routines, comforts, dislikes, or anything that would help us provide more individualized care.

Veterinary Information

Name of primary veterinary practice

Does your dog currently have a veterinarian overseeing their care?

Yes No Not sure

How DidY ou Hear About Us?

Other:

Final Question

Is there anything else you would like us to know before we contact you?

Signature: