CRCG Client Intake Form

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.

Name

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