| Owners Name |
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| Telephone |
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| E-Mail |
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| Address |
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| City |
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| State |
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| Zip Code |
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| Dogs Name |
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| Age |
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| Breed |
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| Spayed/neutered |
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| Male/Female |
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| Veterinarian |
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| Number of Adults in Home |
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| Number of Children |
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| Other Pets in Home species/name/age |
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| Does your dog interact well with other pets? |
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| Is your dog crated at all? |
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| Is your dog housebroken? |
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| Is your dog hyperactive? |
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| Does your dog mount people or objects? |
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| Does your dog urinate when excited or submissive? |
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| Does your dog jump on people? |
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| Is your dog aggressive with other dogs? |
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| Is your dog aggressive towards people? |
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| Does your dog growl at people? |
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Tell us the main problems |
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| What are the 3 most annoying behaviors you want solved |
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