Online Application Form

Location

Dioji Membership is valid at all three locations (Goleta, Santa Barbara and Agoura Hills). Which location would you like to visit for your first FREE day of play?

Goleta Santa Barbara Agoura Hills

Owner Information

Owner's First Name:*
Owner's Last Name:*
Email Address:*
Home Address:*
City:*
State:*
Zip:*
Home Phone:*
Work Phone:*
Cell Phone:*
   

Who should we call to pick up your dog if we cannot reach you?

   
Name 1:*
Phone:*
Name 2:
Phone:
   

In addition to yourself and the individuals listed above, name all who are authorized to pick up your dog:

   
Name 1:
Name 2:
Name 3:
   

Dog Information

Your Dog's Name:*
Sex: Male Female
Breed:
Coat Length:
Birthdate:*
Weight:* Lbs
Veterinarian:
   
   
Is your dog spayed/neutered? * Yes No
Has your dog visited dog parks? * Yes No
Has your dog been to Day Care? * Yes No
Have you boarded your dog? * Yes No
Does your dog like to play with other dogs? * Yes No
Would you like your dog to swim in our pool? * Yes No
Do you use any flea or tick products? * Yes No
   
   
Does your dog have any allergies? * Yes No
If yes, please list:
 
Does your dog have any ongoing medical issues or past injuries? * Yes No
If yes, please list and describe:
 
Does your dog have any sensitive areas? * Yes No
If yes, please list and describe how he/she responds to being touched in these areas:
 
Does your dog display any aggressive behavior when food is present? * Yes No
If yes, please list:
 
Does your dog require any extra handling (muzzle, multiple technicians etc.) during vet visits? * Yes No
If yes, please list and describe:
 
How does your dog respond if another dog attempts to play with his/her toy?
 
How does your dog respond if you take his/her toy away?
 
Does your dog have any specific fears or dislikes? * Yes No
If yes, please list and describe how he/she responds to these:
 
Has your dog ever been in a dog fight or snapped at or bitten someone? * Yes No
If yes, please describe:
 

How did you hear about us?

Web Search Vet Free Day Pass
Drive-by Newspaper Ad
Article TV Commercial
Friend
Other
 

Please type in the alphabets (case-insensitive) displayed above in the box below.

Enter:
 
 
I'd like to add a dog