Dog Information Form

Dog Information Form

Please note that this form does not work properly if attempted via phone, and we will not receive it. It is meant to be completed via computer or laptop. Blind Dog Rescue Alliance (BDRA) recognizes that, due to unforeseen and unfortunate circumstances, owners of blind or visually-impaired dogs may be faced with the difficult decision of surrendering their dog to rescue. If you find yourself in such a predicament and have made reasonable efforts to rehome your blind dog, please fill out the following form with as much detail as possible.
Please note, however, that completion of this form does not guarantee your dog will be accepted into our program or that foster or permanent placement can be made. And again, please also note that this form is meant to be completed via computer and may not work properly if attempted via phone. If you have any difficulties completing this form, please email os@blinddogrescue.org or call 1-877-BLIND-01, extension 4, and we will complete the form with you over the phone.

If at any point you find that you no longer need our assistance, please let us know. We understand that circumstances can change, and we ask that you keep us updated. BDRA is an all volunteer organization, and we appreciate your respect for the time commitments of our volunteers, as well as any potential adopters and/or fosters who may be interested in your dog. Open communication is one of the keys to the success of any organization. We thank you for your cooperation and understanding.

Please also note that we do not currently have any foster homes in the western US; however, we will still do everything we can to help, so please complete the form with as much detail as possible.

First Name *

Last Name *

Address 1 *

Address 2

City *

County

State/Province *

Zip/Postal Code *

Home Phone *

Work Phone

Cell Phone

Email Address *

Information on your blind or visually-impaired dog

Why do you wish to surrender your dog? Please specify. *

What steps have you taken to rehome your dog? Please specify. *

Name of your dog: *

Age or date of birth if known: *

Weight *

Size *

Sex: *

Male

Female

Neutered or spayed? *

Yes

No

If no, are you willing to pay to have it done?

What breed is your dog? *

How long have you had your dog? *

How did you get your dog (for example, adopted as a puppy, adopted from a rescue group (if so, what is the name of the rescue?), the dog was a stray, etc.)? *

Have you contacted your dog's former rescue, breeder, or previous owner (if known)? If no, why not? If your dog is a stray, have you contacted your local shelter to see if s/he has been reported missing? Please also let us know what steps you have taken, if any, to find the dog's legal owner. *

Does your dog have a registration or microchip number? *

Yes

No

If yes, what is that number?

Your dog's temperament and behaviour

Is your dog *

an indoor dog with the run of the house

an indoor dog confined to one area of the house

an indoor dog who is crated

an outdoor dog with a fenced yard

an outdoor dog on a tie-out or chain

an outdoor dog without restrictions

Is your dog housebroken? *

yes

no

Is your dog leash-trained? *

yes

no

Please list any commands your dog knows:

Has your dog had any formal obedience training? If yes, please describe: *

Is your dog (please check any traits that apply) *

Do you own any other animals? *

yes

no

If so, please list:

Is your dog possessive with treats, toys, or food? *

yes

no

Has your dog ever shown aggression to any person or other animal? If yes, please explain: *

Has your dog ever bitten or snapped at anyone and/or at any other animal? *

yes

no

If yes, please give more details. Please include whether your dog has bitten and/or snapped, the circumstances, and if your dog has bitten, whether the bite(s) broke skin.

Do you feel that your dog adapts well to new situations and surroundings despite his or her visual impairment? Please explain: *

Your dog's medical history

Veterinarian's name:

Phone number

* Please advise your vet that we will be calling and give her/him permission to speak with us

Is your dog current with vaccinations? *

yes

no

If no, are you able to pay to have this done?

Has your dog had a heartworm test? *

yes

no

If yes, what was the result?

If no, are you able to pay to have this done?

Please describe in detail your dog's eye(s) condition including cause of blindness or visual impairment, if known, and please include whether your dog is completely or partially blind: *

Has your dog seen a veterinary ophthalmologist? *

yes

no

Please add any other information you have about your dog's overall health: *

In the event a foster home is not found within BDRA, I give permission for my dog to be networked/crossposted via email, websites and Facebook to help my dog find other rescue and/or an adoptive home. I acknowledge BDRA will be listed as the contact and will forward any inquiries to me. I also acknowledge that BDRA will do their best to screen any potential adopter's vetting, but may not be able to do so. I understand BDRA is not able to screen any potential adopters or rescues in any other way, and that BDRA is not able to help with transport.
*

Yes

No

I give permission for my contact information to be shared with other rescues only. *

Yes

No

Is there anything you would like to add as we consider accepting your dog into our program? *

Please attach a photo of your dog: *

Please attach a second photo of your dog:

I certify that the information I have provided is true and correct.

I certify that I am the legal owner of the dog described above, or that I am completing this form on behalf of the owner of the dog described above, and with the owner's knowledge.

I understand that submission of this form does not guarantee that my dog will be accepted into the Blind Dog Rescue Alliance program or that foster or permanent placement can be made. *

I agree

Once you hit submit, the attached photos will be uploaded. This might take some time depending on your internet connection speed. Please do not close this window until you get to the confirmation page.