| OWNER INFORMATION |
|
| Name (First and Last) |
|
| Address (no PO Boxes please) |
|
| City, State, Zip |
|
| Home Phone |
|
| Cell Phone |
|
| Work Phone |
|
| Other Phone (if any) |
|
| Email Address |
|
| Preferred method of contact |
|
| Preferred time of day to call |
Morning
Afternoon
Evening
Night
Any Time |
| |
|
| ANIMAL INFORMATION |
|
| Name of dog |
|
| Is this dog yours or one you found? |
|
| How long have you had this dog? |
|
| What breed(s) of dog is this? |
|
| Is this dog purebred? |
|
| Color(s) of dog? |
|
| Coat length? |
|
| How much does the dog weigh?
(estimate if necessary) |
|
| Sex of dog? |
|
| Age of dog? (if known or
closest guess) |
|
| Is this dog housebroken? |
|
| Is this dog crate trained? |
|
| Is this dog an inside or an outside
dog? |
|
| Does this dog get along with other
dogs? |
|
| Does this dog get along with cats? |
|
| Does this dog get along with small
children (under 5 years old)? |
|
| Does this dog get along with older
children (over 5 years old)? |
|
| Does this dog walk nicely on a leash? |
|
| How does this dog react when left
along? (ie: separation anxiety, destructive, etc.) |
|
| How many hours per day/week is this
dog used to spending alone? |
|
| Is this dog a known barker?
|
|
| Is this dog a known digger (in the
yard)? |
|
| Is this dog afraid of anything in
particular? (ie: men, brooms, thunder, etc.) |
|
| Does this dog like to ride in the
car? |
|
| Describe any training this dog has
had, or tricks it has learned: |
|
| Does this dog exhibit any of the
following behaviors? |
Growls if people go
near him when he's eating
Growls if people go
near him when he has a toy
Growls if people go
near him when he has a treat
None of the above
Other (please
describe)
|
| Has this dog EVER bitten any other
animal? |
|
| If YES, under what circumstances?
Please describe completely |
|
| Has this dog EVER bitten a person
that you are aware of? |
|
| If YES, under what circumstances?
Please describe completely |
|
| Where did you find the dog, or if you
own it, where did this dog originally come from? |
|
| If this was a stray, was this dog
wearing a collar? Tags? Have a tattoo? Was this dog scanned for a
microchip? Please describe in detail: |
|
| |
|
| If a stray, what steps have you taken
to find the owners? Please check all that apply: |
Posted flyers where
dog was found
Posted an ad(s) in the
local paper(s)
Notified the local
animal shelter(s)
Had the dog scanned
for a microchip
Checked
with local vet clinic(s)
Other (please
describe)
|
| |
|
| If this is your dog, what steps have
you taken to re-home him/her? Please check all that apply: |
Spoke with the breeder
of the dog about re-homing
Advertised locally
Advertised on the
internet
Spoke with other
rescue group(s)
Other (please
describe)
|
| |
|
| If this is your dog, why does it need
to be re-homed? Please check all that apply: |
Don't have time for
the dog
Don't have enough room
for the dog
Moving and can't take
the dog with us
Too rough with our
kids
Doesn't get along with
other dog(s)
Dog is
too hyper
Found as a stray,
but can't keep the dog
Other (please
describe)
|
| |
|
| If this is your dog, what steps have
you taken to resolve the problem without re-homing ? What can
we do which might help you keep the dog? |
|
| |
|
| DOG'S MEDICAL INFORMATION |
|
| Is this dog spayed or neutered
(fixed)? |
|
| Is this dog micro-chipped? |
|
| If yes, with what company? |
|
| If yes, will you provide necessary
paperwork and/or permission in writing for the microchip company to
change ownership information over to the rescue and/or a
representative of the rescue organization? |
|
| |
|
| If you own this dog, is it up to date
on vaccinations? |
|
| If YES, which vaccines? Please
check all that applies: |
DHLPP
Coronavirus
Bordatella
Rabies
Lime
Other: Describe: |
| |
|
| Has this dog had a fecal float
recently (to test for internal parasites such as worms)? |
|
| Has this dog been tested for
heartworm? |
|
| If YES, what were the results? |
|
| Is this dog on flea/tick prevention? |
|
| If YES, what brand? |
|
| |
|
| What is the name and phone number of
this dog's veterinarian? |
|
| What is the date of this dog's last
vet visit? |
|
| Can you provide all pertinent medical
paperwork on this dog? (ie: certificate of sterility, proof of
vaccinations, etc.) |
|
| Please list all medications that this
dog is currently taking, and the reason: |
|
| What is this dog's physical health
and condition? Please describe ANY known health problems
completely: |
|
| Are you willing and able to contribute
financially toward medical care and/or boarding/general care for
this dog? |
|
| If YES, how much are you able to
donate at the time of relinquishment? |
|
| How long can this dog safely stay
where it is? |
|