Dog Intake Form Dog Intake Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Dog Name * Owner's Full Name * Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Email * Phone * Gender * MaleFemale Sprayed/Neutered * YesNo Color * Reason for Surrender * How long have you had this dog? * When does the dog need to be rehomed by? * Dog's Age * Date of Birth, if known Weight * Purebred or Mixed * PurebredMixed Breed(s) * How many times a day is the dog fed? * OnceTwiceFree Choice FeederOther Cups per Meal * What type of food(s) does the dog regularly eat? DryCannedOther What brand(s)? * List any allergies(food that causes allergic reactions or does not "agree" with dog) and any known allergies? (Dust, Grass, Fleas, Specific Food, etc) Please, list them out: * Has the dog had any formal obedience training? If yes, what type? * Does dog know basic commands or any tricks? (Sit, Stay, Down, or Others) * Did the dog live in: * HouseApartmentCondoGarageOutdoors in dog houseOther If dog lived inside, where did it sleep or stay?(Check all that apply) * Dog BedFurniture/CouchFloorCrateCellar/BasementIn Bed with Human Is dog allowed on furniture? * YesNo How many hours a day was the dog alone, on average(no human present)? * 8 hours or more6 - 8 hours3 - 6 hours3 hours or lessnever Is the dog housebroken * YesNoPartially Does the dog enjoy exercise? Please explain: * What type of toys does dog enjoy/play with? Please list: * Where does dog NOT like to be touched and please list dog's "like or dislikes" to the best of your knowledge: * Is the dog tolerant of the following? * Ears cleanedNails trimmedBathGroomingWater Does the dog like to swim? * YesNoUnsure Does the dog enjoy car rides? * YesNoSometimes Does the dog get motion/car sick? * YesNoSometimes Please describe the temperament of dog: * Is the dog "hand shy"? * YesNo Does the dog spook easily? * YesNo Please list anything the dog is afraid of (loud noises, thunder, men, veterinarian, certain objects, and etc) * Please list any "bad habits" or behavioral problems the dog has: (chews furniture/clothing, digs holes, jump fences, barks excessively, bites, separation anxiety, etc) Be specific. Please explain: * Has the dog lived or been around: * Small ChildrenOther DogsCatsBirdsSmall AnimalsAdults OnlyOther Was dog an "only" dog, or in a multiple dog household? * Only Multiple Is there any dog aggression? * YesNo Please explain if dog has ever bitten anyone? * Any problems with: * EyesightHearingNeither Has dog ever been injured or had serious illness? Please explain: * Does the dog have any chronic medical condition? Please explain: * Is dog presently on any medication? If Yes, please list all medications: * Is dog up to date with vaccines: * ShotsHeartworms PreventativeRabies When were vaccines last given?(shots, heartworms preventative, rabies) * Brand of heartworm preventative being used and last date given: * Please list all medication(s) dog is presently on: * Name, phone number and address of your veterinarian: * Please tell us any additional information about your pet that will help us place him/her in a loving home. * Initial *