Forms

Which CRCG location are you visiting?*

CRCG Broomfield
CRCG Englewood

Client Information

Name*

First Last

Address

Street Address Address Line 2 City State ZIP Code

Email

Today's Date

Mobile Phone

Home Phone

Work Phone

Other Guardian Name

First Last

Pet Information

Pet Name*

First Name

Breed*

Date of Birth (if unknown, see next question)

If the DOB is unknown, what is your pet's estimated age?

Family Veterinarian Name*

Clinic Name*

Current Medications

Rabies/Distemper Expiration

Sex*

Male
Female

Spay/Neuter*

Yes
No

Current Health Information

Does your dog have any condition that we should be aware of such as recent surgery, injuries, treatment, been sick lately or have a need for daily medication?*

Yes
No

Details

Has your dog harmed any person or shown aggressive behavior towards any person or any other dog?*

Yes
No

Details

Consent*

I agree to the swim and play rules.

Swim & Play Rules can be found at http://dog-swim.com/wp-content/uploads/2020/11/CRCG_SwimPlayRules.pdf

How did you hear about us?*

Friend
Vet
Other Dog Healthcare Provider
Promotion
Web search
Advertising
Other

Details

Do we have your permission to add you to our CRCG newsletter mailing list?*

Yes
No

ie: Monthly specials, Holiday theme parties, fundraisers, contests, game days, etc. (Note: CRCG does not share or sell your contact information. All information is confidential.)

How would you like to be contacted with appointment reminders?*

Additional Pets

Do you have any additional pets?

Pet Name

First Name

Breed

Date of Birth

Sex

Male
Female

Spay/Neuter

Yes
No

Rabies/Distemper Vaccination Expiration Date

Please note all medications you currently give your dog.

What brings you to CRCG?*

Rehabilitation
Recreational Swimming

My dog is healthy and not under treatment at this time.*

Yes
No

Details

Please note if this dog is under any treatment provided by a vet or if there are health problems or concerns of which you would like us to be aware.

Comments

This field is for validation purposes and should be left unchanged.

Forms

CRCG Client Intake Form

Client Information

Pet Information

Current Health Information

Additional Pets