E-mail Address: * |
|
Dog Name * |
|
|
|
Age * |
|
Birthdate (If known) |
|
Sex * |
Male
Female |
Spayed or Neutered * |
Yes
No |
Current Weight * |
|
Microchip * |
Yes
No |
Microchip Supplier |
|
Microchip Number |
|
Type of Dog * |
|
Size * |
|
Color * |
|
Immunizations and Shots Up to Date? * |
Yes
No |
Next Immunizations Due: * |
|
Bordatella Due: * |
|
Rabies Due: * |
|
Flea and Tick Due: * |
|
Heartworm Due: * |
|
Veterinarian Name: * |
|
Veterinarian Street : * |
|
Veterinarian City: * |
|
Veterinarian State and Zip Code: * |
|
Veterinarian Phone: * |
|
Veterinarian Fax: |
|
Veterinarian e-mail: |
|
List Allergies: |
|
List Other Medical Conditions: |
|
List Medications: |
|
Food Currently Feeding:* |
|
Reason for Rehoming (PLEASE be very honest so we can be honest with potential adopters) * |
|
Can the dog remain in your home until a new home is found? * |
Yes
No |
If no, what is the deadline? |
|
Can you assist in transporting? * |
Yes
No |
Dog Skills and Knowledge |
|
Crate Trained? * |
Yes
No |
Still using Crate? |
Yes
No |
How long in the crate in a 24 hour period? |
|
House Trained? * |
Yes
No |
Walks well on a leash?* |
Yes
No |
Type of Collar used for walking? * |
|
Obedience Training? * |
Yes
No |
If yes, to what level |
|
Can your dog do the following: * |
Sit
Down
Come
Heel
Leave it
Stay
None of the Above |
Has the dog ever run away/escaped? * |
Yes
No |
If yes, how many times? |
|
Does the dog currently have a fenced yard? * |
Yes
No |
If yes, what type of fence? |
|
If you have an e-fence do you have any problems? |
|
Does your dogs get along with.... * |
Most men
Most women
Most Babies
Most Children under 12
Most Children over 12
Most dogs
Most Cats
Most Other Animals |
Dogs your dog typically jump on people? * |
Yes
No |
How does your dog react to strangers? * |
|
Does your dog bark excessively? * |
Yes
No |
Does your dog have separation anxiety? * |
Yes
No |
Dog Hair Shed Factor * |
|
Select Answer Which best Describes your Dogs Coat. * |
|
Describe general temperament of your dog. * |
|
Has your dog Bitten anyone? * |
Yes
No |
If yes, please provide ALL details |
|
Where did you get your dog? * |
|
Is this the dogs first home (beside the original breeder)? * |
Yes
No |
If no, please provide the history of where this dog came from. |
|
Name of Breeder (If applicable) |
|
Has the breeder been notified that you are wanting to rehome? * |
Yes
No
Does Not Apply |
If yes, what was their response? |
|
If no, why have you not contacted them? |
|
Your Information |
|
Owners Name * |
|
Owner Street: * |
|
Owner City * |
|
Owner State * |
|
Owner Zip Code * |
|
Owner Phone Number * |
|
Owner Alternate Phone |
|
Agreements: |
|
If any information on this form changes you will contact us immediately. * |
I Agree to contact you. |
If you find a home for the dog on your own you will contact us IMMEDIATELY * |
I Agree! |
Please include any additional information or comments, including any other rescue or shelter this dog is listed with: |
|
|
|