Dog Intake Form
*
Name:
Name of Organization (if applicable):
*
Street Address:
*
City:
*
State:
*
Zip:
*
Phone Number:
*
Email address:
*
Why is this dog being released to rescue?
*
Where did this dog live?
Inside
Outside
Unknown
*
Name of Dog:
Attach a photo if available:
*
Sex of Dog:
Male
Female
*
Is dog intact?
Yes
No
*
Approximate Age of Dog:
*
Style of Ears:
Natural
Cropped
*
Style of Tail:
Docked
Natural
*
How long has this dog been in your custody?
*
Is this dog good with adults:
Yes
No
Unknown
*
What food has this dog been eating?
Explain if needed:
*
Is this dog good with children:
Yes
No
Unknown
Explain if needed:
*
Is this dog good with other dogs:
Yes
No
Unknown
Explain if needed:
*
Is this dog good with cats:
Yes
No
Unknown
*
Has this dog ever been used for breeding purposes?
Yes
No
Unknown
Explain if needed:
*
Are Vaccines Current:
Yes
No
Unknown
*
Heartworm Status of Dog:
Negative
Positive
Unknown
*
Vet's Info (List name, address and phone number):
*
Do we have permission to contact your veterinarian in order to obtain medical records for this dog?
Yes
No
N/A - This dog is in a shelter.
*
Can you transport to us?
Yes
No
Maybe
If this dog is currently taking medication(s) please list below:
If this dog has any known allergies, please list them below:
If this dog has had any surgeries other than spay/neuter please list them below:
*
Does this dog have basic training?
Yes
No
Unknown
Please choose the following activities the dog likes:
Children
Water
Walks
Other Dogs M/F
Swimming
Sitting In Laps
Cats
Car Rides
Baths
Strangers
Playing
Retrieving
Please check any of the following that apply to dog:
Barks Excessively
Kills Cats
Jumps Fences
Digs
Chases Moving Things (ex. cars)
Runs Away
Chews
Behaves Aggressively
Has High Prey Drive
Guards Food From Humans
Guards Food From Animals
Guards Toys From Humans
Guards Toys From Animals
*
Is this dog house trained?
Yes
No
Unknown
*
Has this dog ever displayed aggression toward humans or other animals to the best of your knowledge?
Yes
No
If Yes, Please Explain Below:
If this dog has any other behavioral problems, please use the space below to describe these problems:
*
Has this dog ever bitten anyone?
Yes
No
Unknown
If yes, please use the space below to describe any and all bite incidents:
*
Does this dog have any medical issues?
Yes
No
If yes, please use the space below to describe these issues:
*
Please tell us about this dog's positive traits below:
*
Please tell us about the dog's negative traits below:
*
When does this dog need to come to rescue?
*
How did you find DDR?
Additional Comments:
*
E-Signature - By entering your name in the space below you agree that all of the information you have provided in this form is true and correct to the best of your knowledge.
*
Indicates Response Required
Powered by
FormSite.com