New Client Intake Form Opus Media July 6, 2017 August 18, 2017 Information about you and your pup so we can provide the best training and care possible. Step 1 of 7 14% Name* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country How did you hear about us?*GoogleVehicle AdFacebookMailed FlyerMagazineInstagramBingTVReferral Pet InformationDog Name*Breed*Age*WeightSex*MaleFemaleWho is Authorized to Pick Up Your Dog?*Emergency Contact Name*Emergency Contact Phone* Medical InformationVeterinarian's Name*Veterinarian's Phone Number*Do you agree to have your dog seen at the nearest veterinarian in case of emergency?*YesNoDoes your dog have allergies?*YesNoPlease list allergies here.Does your dog take any medications?*YesNoPlease list medication, dose and time given Vaccination RecordsAll dogs are required to be up to date on Bordatella, Distemper, and Parvovirus. *Four weeks must elapse after the final dose of Parvovirus for the dog to be immune, only in-home training may be conducted prior to immunity.Please upload a photo or scanned copy of your dog's vaccination record here.* Dog HistoryCheck all that apply to your dog. Crate Trained House Trained Growls or bites Bitten a human Bitten other dogs Allows me to brush their fur Allows me to trim their nails Pulls on leash Has separation anxiety Food aggressive Toy aggressive Jumps / escapes fences Pees in crate Destroys bedding Has your dog received training before?*YesNoWhat training, how long ago, and where?Is there anything you would like to add about your dog's behavior? If your dog exhibits and aggressive behavior, please provide details about it. K9 Kompliance TrainingWhat are your training goals?*Is your dog boarding with us?YesNoPlease list any specific boarding related needs.Boarding Drop-off Date: Boarding Pick-up Date: Dog food brand and feeding instructions.* Legal AgreementsGeneral Policy K9 Kompliance will endeavor to create as safe an environment as possible for the training and boarding care of the dog(s) identified above (the “Dog”), and will offer only sound, safe, and responsible training, care, and post-boarding training instructions. Owner agrees, however, that all animals may exhibit unpredictable behaviors and that K9 Kompliance will not be liable for the actions of the Dog that are outside of the control of K9 Kompliance. Owner agrees to allow random stool samples to insure saftey of kennel. Owner agrees that the recommendation by K9 Kompliance of any product or service is not a guarantee of performance or Owner’s satisfaction with that product or service. K9 Kompliance agrees to indemnify and hold Owner harmless from and against any claims of injury, expense, costs, loss or damages caused by the gross negligence or willful misconduct of K9 Kompliance while the Dog is in the sole cus, ody, care and control of K9 Kompliance. Owner acknowledges that K9 Kompliance has no control over the Dog when the Dog is not in the exclusive custody, care and control of K9 Kompliance, and Owner agrees to indemnify and hold K9 Kompliance harmless from and against any and all claims of injury, expense, costs, loss or damages caused by the actions of the Dog when the Dog is not the sole custody, care and control of K9 Kompliance.Owner acknowledges and agrees that owning any animal, including the Dog, has inherent risks, including but not limited to the risk of dog bites to Owner * Owner acknowledges and agrees that owning any animal, including the Dog, has inherent risks, including but not limited to the risk of dog bites to Owner Owner fully understands the tools and techniques that are used to train and modify the behavior of their dog and agrees to the tools and techniques which include Prong Collar, Remote Training Collar, Slip Lead, Muzzles, Flat Buckle collar, Martingale collar. Payment & Cancellation Policy Payment Policy: In order to reserve your dog's Board & Train program, you must pay 100% of the fee in full. You will receive an invoice for your dog's training program; we only accept payments via Quickbooks. Cancellation Policy: If the client chooses to not continue training after receiving approximately 50% of services, a refund will not be issued unless at the sole discretion of K9 Kompliance. If we do grant a refund, it is because we are making a one time exception to our general rule of not issuing refunds. If the trainer feels that the client will not listen to training advice or follow instructions, K9 Kompliance can, at our sole discretion, choose to cancel the training contract and issue a partial refund. Non-disparagement: The client agrees that no public reviews will be left with a rating of less than 4-stars by them or anyone referencing their transactions with the company. Disparagement penalty is $1,000 or an amount equal to services scheduled, whichever is greater. For Board and Train: The total Board & Train fee includes a $100 non-refundable deposit. The remainder of the Board & Train fee is 100% refundable up until 10 days prior to your dog’s scheduled drop-off date. If you cancel within 10 days prior to the scheduled drop-off date, no refunds will be given, except at the sole discretion of K9 Kompliance. By signing below you agree to the terms outlined above in the General Policy & Payment and Cancellation Policy shown above.SignatureCAPTCHAwebformNameThis field is for validation purposes and should be left unchanged.