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Behaviour Questionnaire

This form is to be completed once referral from your local veterinarian has been established.

Please complete the below questionnaire about your dog. All information will be securely sent to info@woodsveterinarybehaviour.com.

Please let me know if you need this document in a different format or would prefer it to be posted to you.
A PDF of this form can be downloaded by clicking here.
Once I have received this I will send you a link from which you can schedule and pay for the consultation.

Title:

First Name:

Email:

Last Name:

Phone:

Address:

Occupation:

Family members:

Referring Veterinary clinic

Referring Veterinary surgeon

Is your pet insured?

Yes

What is the company and policy name?

Is your pet covered for behaviour?

Yes

What is the company and policy name?

Your pet's details:

Name:

Sex/neuter status:

Date of birth:

Date of Neuter:

Age:

Weight:

Breed:

Other pets in the house hold?

Introductory questions:

Where did you adopt your dog from?

At what age did you bring your dog home?

Where and for how long does your dog sleep at night?

Where and for how long does your dog sleep in the day?

What does your dog get fed?

What are your dog's favourite foods?

Is your dog a fussy eater at times?

Yes

How often and for how long do you walk your dog?

What equipment do you use to walk your dog?

Is your dog currently on any medications or supplements (including for behaviour)?

Has your dog previously been on any medications or supplements for behaviour?

Behaviour questions:

Please describe the problems you are having with your dog:

When did you first notice this occuring?

How would you describe how your dog greets unfamiliar people?

Does your dog show aggression?

Has your dog previously bitten someone? If yes, please provide details.

Has your dog previously bitten another animal? If yes, please provide details.

Has your dog previously attended private or group training classes?

Any extra comments or details you would like to add?

Consent:

Based on the information provided by email, by completing and returning this form you are agreeing to proceed with the referral process.

First Name

Last Name

Data Consent:

Woods Veterinary Behaviour collects and processes the above personal data when you engage with our services and will be treated as strictly confidential. This information needs to be collected and retained in order to facilitate the service of behavioural referral, involving internal record keeping and completion of correspondence with you and your referring veterinarian. You are under no obligation to provide us with your personal data but failure to do so will hinder the service we can provide to you. All data collected will be used solely for this purpose and will not be shared with third parties except with your referring veterinarian unless further consent is given.

Due to the nature of our business we need to store data for a long time for insurance purposes and in case of re-referral. Unless you request us to remove your personal data, we will retain it for a minimum of 15 years after last contact, after which it may be securely deleted.

If you would like a copy of the personal data we hold, believe any of your information in our possession is incorrect, wish to cease correspondence with us or for us to remove your information from our system, please contact us and we will take the necessary steps subject to legal regulation - within 28 days of receipt.

I consent to my information being collected and processed as outlined above:

Yes

Video and photo consent:

During the consultation, videos and pictures may be taken to facilitate assessment and enable review of observations gathered during the consultation.

I give consent for: Videos and photos to be taken and used only for the purposes of the consultation

Yes

Videos and photos to be taken and used for educational and promotional purposes on the Woods Veterinary Facebook page and/or website.

Yes

Thanks for submitting!