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Canine Initial Behavior Appointment

Important: Please ensure that after filling out this form in its entirety that you are fully clicking "Submit" at the bottom of the form. This will take you to a confirmation page, noting that your form submission has been sent to our team. 

Basic Information

Patient's Information
Owner's Information
Co-Owner's Information

Household Information

Acquisition Information

Medical Information

Neuter/Spay Information
Medical History
Check all of the vaccinations your dog is up to date on:

Please list all medications/ treatments your dog is CURRENTLY receiving, including heartworm, flea/ tick preventative/ collars, dietary supplements, herbal/homeopathic treatments:

Daily Activities/ Routine
Meals/ Types of Food
Eating Habits (Check all that apply)
How is your dog fed? (Check all that apply)
If disturbed when sleeping, what is your dogs reaction?
Have you made any changes to where your dog sleeps because of their reactions to being disturbed?
Living Spaces/ Being Left Alone:
Where does your dog spend most of their time when people are home?
If people are in the house but your dog is separated from them, how do they react?
What is your dog's reaction to being left alone? (Check all that apply)


If you answered no, why?
What do you use to walk the dog? (Check all that apply)
What are your dogs favorite toys? (Check all that apply)
How does your dog play with toys? (Check all that apply)
What type of training?
What training techniques have you used?
How does your dog react to the following:
Unfamiliar people at door to house
Unfamiliar people in home
Unfamiliar people away from home while off leash
Unfamiliar people away from home while on leash
People on bicycles, roller blades, etc. (while on leash)
Joggers (while on leash)
Cars/ Trucks going by while on-leash
Unfamiliar dogs, when your dog is on-leash
Unfamiliar dogs while your dog is off leash
Squirrels/ Cats/ Small Animals
Dog in yard and person passes by outside of the yard
Veterinarian's Office
Stranger approaching car when dog is inside
Loud Noises
How does your dog react to a family member doing the following:
Walk by dog while they are eating a regular meal
Reach for or take food dish while dog eats regular meal
Walk by while dog eats more delicious food
Reach for/ take away non-edible toy (ie. ball, stuffed animal)
Reach for/ Take away edible bone/ rawhide
Take away stolen non-food item (ie. socks)
Take away stolen food item (including dirty tissues, paper towels, food wrappers)
Reach for dropped food at same time as dog
Reach over head/pet on top of head
Pet on other parts of body
Pick dog up
Put on/ off collar
Put on/off leash
Disturb while sleeping
Move while on furniture
Dog is sitting with one family member and another family member approaches
when held back when excited (ie. from running out doog) NOT WHEN AGGRESSIVE)
When held back when showing aggression (ie. barking at another dog)
Verbal reprimand
Leash correction
Physical reprimand
Someone staring at your dog
How does your dog react to a dog in the household (if your dog doesn't regularly spend time with another dog you don't need to fill out):
Around regular food
While on walks together
Around favorite people
Around toys
Around Treats
Around rawhides
During play
How bad was the worst bite your dog ever gave to a person (check all that apply):
Primary Behavior Problem

Please fill out this section IN DETAIL. The more completely the form is filled out the more time it will allow us to spend during the appointment discussing treatments instead of going over your dog's history:

* Important! Please include the following in your description:Where the incident occured, who else (human/animal) was present, what happened just before the incident, how everyone present reacted. If you noticed any changes in your dog's body language or facial expression before, during or after the incidents please describe.

Try to remember the earliest occurence of the problem, even if it wasn't as serious as it is now. For example, if your dog is aggressive to people, describe the first time she growled or barked at someone, not the first bite. Or if your dog has problems being left home alone, describe the first time he/she whined and cried when you left, not just the first time he ripped up the carpet.
Frequency of Primary Behavior Problem:
Is the frequency...
What percent of the time that your dog is in a potentially problematic situation does the problem behavior occur?
What have you tried to do to correct this behavior problem and how did your dog respond?
Have you ever considered euthanasia or rehoming your dog because of this problem?
*Please understand that this is not a recommendation or a suggestion. It is simply important for us to understand a full picture in our assessment. 
How serious do you and other members of the household find this problem?
*Please understand that this is not a recommendation or a suggestion. It is simply important for us to understand a full picture in our assessment. 
Do we have permission to post pictures on our social media?

As the representing owner, agent or handler dealing with the individuals who will be working with the pet(s) indicated above, I understand that behavior therapies recommended by Dr. Laurie Bergman may involve some level of risk to the pet(s) and or the handlers, or other people or property in spite of our best efforts to minimize them. I will use my own judgement and common sense when following any recommendations so as not to place people, pets and property at undue risk.

Furthermore, I realize that the clinicians, Hickory Veterinary Hospital and its agents/ employees cannot guarantee that a pet will not be aggressive or cause injury to people or property in the future and I acknowledge that the pet's owner(s) and handler(s) continue to be solely responsible and assume all liability for any future aggression or misbehavior.

By typing my name below, I am freely assuming these risks and shall not hold Hickory Veterinary Hospital or its clinicians, agents, employees or facility owners liable for any loss or injury which may occur to handlers, pet, or other people, other animals or property while using their training and medication treatment recommendations, and I hereby waive any claim for damages arising out of such matters and agree to hold Hickory Veterinary Hospital and its clinicians/ agents/ employees harmless from any such claims.

***Behavior initial consults are $420 and a 50% deposit is required to schedule

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