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CRCG Client Intake Form
We require all our new clients to complete and sign this intake form prior to the first appointment.
Which CRCG location are you visiting?
*
CRCG Broomfield
CRCG Englewood
Client Information
Name
*
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Last
Address
Street Address
Address Line 2
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MM slash DD slash YYYY
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First
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Pet Information
Pet Name
*
First Name
Breed
*
Date of Birth (if unknown, see next question)
MM slash DD slash YYYY
If the DOB is unknown, what is your pet's estimated age?
Family Veterinarian Name
*
Clinic Name
*
Current Medications
Rabies/Distemper Expiration
MM slash DD slash YYYY
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?
*
Email
Text Message
Mobile Phone
Home Phone
Work Phone
Additional Pets
Do you have any additional pets?
Yes
No
Pet Name
First Name
Breed
Date of Birth
MM slash DD slash YYYY
Sex
Male
Female
Spay/Neuter
Yes
No
Rabies/Distemper Vaccination Expiration Date
MM slash DD slash YYYY
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.
Name
This field is for validation purposes and should be left unchanged.
CRCG Client Intake Form
CRCG Liability Agreement
CRCG Veterinary Referral Form
Chinese Herbal Medicine Refill Form