subject_line
Surrender/Intake Form
First Name:
*
Last Name:
*
Address:
*
City:
*
State:
*
Zip Code:
*
Email Address:
*
Phone Number:
*
Name of dog:
*
Sex of dog:
*
Male
Female
Breed of dog:
*
Age of Dog:
*
Photo of dog:
Time frame you have owned dog:
*
Reason for surrendering dog:
*
Time frame to surrender dog:
*
Is the dog housetrained?
*
Yes
No
Unknown
Is the dog current on vaccines?
*
Yes
No
Unknown
Is the dog spayed or neutered?
*
Yes
No
Unknown
Heartworm status of the dog:
*
Positive
Negative
Unsure
Does the dog have basic training?
*
What food is the dog currently eating:
*
When was dog last seen by a veterinarian?
*
Has the dog had any other surgeries or procedures?
*
Has the dog ever been used for breeding?
*
Yes
No
Unknown
Does the dog have any other medical conditions?
*
What is the dog's approximate weight and size.
*
Does this dog like people?
*
Yes
No
Unknown
Does this dog like children?
*
Yes
No
Unknown
Does this dog like other dogs (large and small):
*
Yes
No
Unknown
Does the dog like cats?
*
Yes
No
Unknown
Has this dog ever bitten a human?
*
No
Yes
Yes
Has this dog ever bitten another dog?
*
No
Yes
Yes
Please check any of options below that apply to the dog:
*
Barks a lot
Jumps fences
Runs away
Housebroken
Chews
Crate trained
Guards food from humans
Guards food from animals
Has a high prey drive
Please check any of options below that apply to the dog:
*
Likes people
Likes children
Likes other dogs
Likes cats
Likes water
Likes going in the car
Likes baths
Likes swimming
Likes the vet
Additional information you wish to provide on the dog:
How did you hear about our organization?
*
By entering your full name in the field below, you are attesting that all information on this form is correct to the best of your knowledge.
*