DATE:
NAME:
ADDRESS:
CITY, STATE, ZIP
PHONE #:
E-MAIL:
REASON FOR CALL:
a) WANT TO SURRENDER DOG
b) HAVING PROBLEM WITH DOG AND NEED ADVICE
IF YOU WANT TO SURRENDER, WE NEED THE FOLLOWING INFO ALONG WITH A CURRENT PHOTO OF YOUR DOG:
IS THIS YOUR OWN DOG OR A STRAY?
IF A STRAY, HOW LONG HAVE YOU HAD THE DOG AND HAVE YOU PROVIDED ANY VETERINARY CARE OR GROOMING?
WHO HAVE YOU CONTACTED OR WHAT HAVE YOU DONE, IN AN EFFORT TO FIND THE OWNER OF THIS DOG?
DOG'S NAME:
SEX:
SPAY/NEUTERED?
AGE:
COLOR:
WEIGHT:
HEIGHT TO SHOULDER:
IS THIS DOG MICROCHIPPED?
IS THIS DOG TATTOO'D?
WHERE WAS DOG PURCHASED?
PET STORE
BACKYARD BREEDER
BREEDER (who) ?
AKC PAPERS?
HOW MANY HOMES HAS THIS DOG BEEN IN?
HOW LONG HAVE YOU HAD THE DOG?
HOUSEBROKEN?
SUBMISSIVE WETTER?
HOW IS THIS DOG FOR GROOMING AND BATHING?
NAME ADDRESS AND PHONE NUMBER OF CURRENT GROOMER:
HOW DOES THIS DOG BEHAVE AT THE VET'S OFFICE?
DOES DOG?.
JUMP FENCES?
DO ANY DIGGING?
DO ANY DESTRUCTIVE CHEWING?
IS DOG A BARKER?
DO ANY SNARLING?
IF YES, PLEASE EXPLAIN DETAILS:
SNAPPING?
IF YES, PLEASE DESCRIBE DETAILS:
HAS DOG HAD ANY TRAINING?
WHAT KIND?
DOES THIS DOG DO ANY TRICKS? WHAT?
DOES THE DOG KNOW BASIC COMMANDS?
WALK ON LEASH, NICELY OR TUGS A LOT?
DOES DOG LIKE RIDES IN CAR
GET CARSICK?
CRATE TRAINED?
IS THIS DOG ACCUSTOMED TO BEING ALLOWED ON FURNITURE? ( The reason for this question is that, I do not place dogs who were previously allowed on the furniture, in homes that do not permit it. I hold out for a similar home who will allow it. I don't think it's fair to the dog)
HOW IS DOG WITH CHILDREN?
HOW IS DOG WITH MEN AND WOMEN?
HOW IS DOG WITH STRANGERS?
HOW IS DOG WITH CATS?
OTHER DOGS?
HOW DOES THIS DOG BEHAVE WHILE BEING GROOMED?
IS A MUZZLE OR SEDATION REQUIRED FOR GROOMING OR VET VISITS?
HOW MANY TIMES HAS THIS DOG BITTEN?
PLEASE EXPLAIN, INCLUDING WHO, WHEN, AND WHY:
DESCRIBE GENERAL TEMPERAMENT:
REASON FOR RELEASING?
MEDICAL HISTORY:
SHOTS, WHICH & WHEN?
DHLPP?
RABIES?
BORDATELLA?
LYME?
OTHER?
HEARTWORM TESTED?
ON PREVENTATIVE? (WHICH ONE?)
DATE AND BRAND OF LAST FLEA PREVENTATIVE:
ANY MEDICAL PROBLEMS?
ANY CHRONIC PROBLEMS WITH EAR INFECTIONS?
ON ANY MEDICATIONS?
ANY ALLERGIES?
HAS THIS DOG HAD ANY SURGERIES?
WHAT BRAND OF DOG FOOD IS THIS DOG ACCUSTOMED TO EATING?
WHAT IS THE CURRENT CONDITION OF THIS DOG --
Freshly groomed ~ Groomed several weeks ago ~ Dirty but clipped short ~ Dirty and some mats ~ Filthy and severely matted???????????
DOES THIS DOG HAVE FLEAS OR TICKS?
WHAT VET DID THE SPAY/NEUTER? NAME, ADDRESS, AND PHONE NUMBER.
PHONE ?
TREATING VETERINARIAN:
PHONE:
ANYTHING ELSE WE SHOULD KNOW ABOUT THIS DOG'S HEALTH, HABITS, OR BEHAVIOR?
IF WE ACCEPT THIS DOG INTO OUR FOSTER CARE PROGRAM, ARE YOU WILLING/ABLE TO MAKE A DONATION TO HELP WITH THE CARE OF THIS DOG? (Dogs are NOT turned away if the owners are truly unable to make a donation.)
