Client Intake Form

Freedom Paws Canada

Prototype only — not connected to a database.
Do not enter real or sensitive personal or medical information into this demonstration. It does not submit, save, or transmit anything. Database storage and access controls will be considered after FPC approves the privacy and security approach.

Record Reference

Intake number

Temporary administrative reference only. A permanent team number is assigned at graduation, not at intake.

1. Applicant Information

First Name

Last Name

Street Address

City

Province (Prov)

Post Code

Daytime Phone

Employment Status

Vet? 1st Responder? Other

2. Emergency Contact

Emergency Contact

Phone Number

3. Dog Evaluation

Do you have a dog you would like to have evaluated?

Yes No

A. Dog's Name

B. Dog's Age

C. Dog's Breed

D. Microchip or Tattoo

E. Vet's Name

F. Vet's Phone

4. Service Dog Assistance Needs

Why do you feel you require the aid of a service dog? Select Yes or No for each item.

Please specify

5. Handler and Training Information

Tell us about the person who will be working with the service dog, including any prior experience with K9s.

Is there any medical condition or medications that we would need to be aware of during your training?

Sensitive-information field shown for layout review only; nothing is saved.

A medical referral form will be required; will you be able to provide this from your medical practitioner? (The form will be provided.)

Yes No

6. Living Situation and Other Pets

Does your current living situation allow you to afford and accommodate a service K9? (A home visit will be required prior to placement.)

Yes No

Do you have other pets residing in the home? Please describe.

Do you have concerns or questions about leasing a Freedom Paws Canada service dog?

7. Applicant Confirmation

Signed (type name for prototype)

Dated

Staff Use Only — Record Status

For staff to mark the intake record. Choose the appropriate status; these checkboxes are a visual prototype and are not saved.

Active Non-Active Dog Change

Back to Intake Page Back to Client Dashboard