Name
*
First Name
Last Name
Address:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email:
*
Phone
*
(###)
###
####
Are you the legal owner of the dog?
*
Yes
No
If no, please explain.
Dog's name:
*
Dog's age:
*
Dog's sex:
*
Male
Female
Please let us know the reason you can no longer keep your dog, in as much detail as possible:
*
How did you obtain this dog?
*
How long have you had this dog?
*
How many previous owners has this dog had?
To the best of your knowledge, if applicable.
Why did the previous owners give up this dog?
To the best of your knowledge, if applicable.
Has the dog seen a vet before?
*
To the best of your knowledge. If you are able to, please specify which veterinary clinic.
Is the dog spayed or neutered?
*
Yes
No
Has the dog had any other surgeries?
*
Yes
No
If yes, please explain.
Does the dog have any known allergies, skin, or ear problems?
*
Yes
No
If yes, please explain.
Has the dog had all of its vaccinations?
*
Yes
No
I'm not sure
What and when were the dog's last vaccinations?
To the best of your knowledge, if applicable.
Does the dog eat table scraps?
*
Yes
No
Does the dog have any scars or deformities?
*
Yes
No
If yes, please explain.
Does the dog have any other known health problems?
*
Yes
No
If yes, please explain.
Does the dog mind being handled?
Yes
No
Does the dog mind being brushed?
Yes
No
Does the dog mind having its nails clipped?
Yes
No
Has the dog ever seen a groomer?
To the best of your knowledge. If you are able to, please specify which groomer.
Is the dog housetrained?
*
Yes,
No
Mostly, only occasional accidents
A little, potties both indoors and outdoors
If not entirely housetrained, please describe the frequency of accidents.
Does the dog signal or let you know when they need to go out to potty?
*
Yes
No
If yes, please describe how they let you know or signal.
Does the dog chew things it isn't supposed to?
*
Yes
No
Sometimes
Rarely
If yes, please explain the types of things the dog chews and when it chews these things.
Is the dog used to being left alone?
*
Yes
No
If yes, how long are they used to being left alone?
Is the dog currently crate trained?
*
Yes
No
If yes, please elaborate.
How do they react to being crated? Are they crated for extended hours? Are they crated when left alone? Are they crated at night?
Has the dog been kept outside unsupervised for extended hours?
*
Yes
No
Has the dog been kept on a chain outside unsupervised for extended hours?
*
Yes
No
Does the dog chase or any of the following?
*
To the best of your knowledge.
Does your dog bark at any of the following when on leash?
*
Does the dog jump fences?
*
Yes
No
I'm not sure
Does the dog bark excessively indoors?
*
Yes
No
Does the dog run away if it is off leash?
*
Yes
No
I'm not sure
Is the dog used to riding in the car?
*
Yes
No
I'm not sure
Has the dog been to obedience training?
*
Yes
No
I'm not sure
Does the dog walk well on a leash?
*
Yes
No
If no, please elaborate.
Has the dog been exposed to any of the following training tools?
Please check all personality traits that apply to the dog.
*
This dog is friendly with:
*
Has the dog ever met other dogs?
*
Yes
No
Unsure
If yes, how did they react?
Has the dog ever met cats?
*
Yes
No
Unsure
If yes, how did they react?
Has the dog ever met children?
*
Yes
No
Unsure
If yes, how did they react? How old were the children?
Please list anything this dog is afraid of:
To the best of your knowledge, has this dog ever been physically abused or mistreated? Please explain.
Please select any and all commands the dog knows.
What are your dogs favourite games or toys?
Does your dog have any cute mannerisms or habits that would be interesting to new owners?
Has your dog every growled over the following?
If other, please explain.
Does your dog have a bite history with any of the following?
If other, please explain.
Please share with us any other comments you feel are important.
Are you willing to contribute a surrender donation of $50 to the rescue? This donation helps to offset the financial burden the rescue incurs while your dog is in our care.
Yes
No
Unsure
I certify to the best of my knowledge, the information provided in this form is true as of the date of this form. I agree that submission of this form will constitute a legally signed document.
*
Agree
Do Not Agree
Signature:
*
Date
*
MM
DD
YYYY
