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Name:
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Street Address:
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City/State/Zip:
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Daytime Phone Number:
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Evening Phone Number:
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Other Phone Number:
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Best Time to contact you:
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Email Address:
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Dog's Name:
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Rabies Tag Number:
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Dog's Date of Birth:
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How was dog originally acquired?
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When Acquired?
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Why must dog leave your home?
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When does dog have to leave your home?
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What is the dog's color?
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What is the dog's Height/Weight?
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What is the sex of the dog?
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Female
Male
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What is the dog's tattoo, if he/she has one?
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What is the dog's microchip number and who is it with?
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Please describe any scars, broken teeth, etc.
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What is the name, address and phone number of the veterinarian you have taken the dog to?
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Date of last visit for this dog?
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Date of last DHLP:
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Date of last Rabies shot?
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Date of last Bordetella?
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Please list type and date of any other vaccinations this dog has received?
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Date of Heartworm Test:
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Result:
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Negative
Positive
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Currently on Heartworm Prevention?
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Yes
No
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If so, what Brand?
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Is this dog spayed/neutered?
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Yes
No
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Does this dog have any allergies, if so what kind?
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Does this dog have any medical problems, if so please describe?
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Has this dog had any surgeries, if so please describe.
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Has this dog ever required emergency care? If so please describe.
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Current Dog Food?
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Current feeding schedule and quantity:
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Please check all the personality traits that apply to this dog. (please check all that apply) LIKES
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Dogs
Cats
Small Animals
Children
Strangers
Visits to Vet
Crates
Car Rides
Toys/Play
Water
Being Groomed
Traveling
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Please check all the personality traits that apply to this dog. (please check all that apply) DISLIKES/HABITS
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Dog Aggression
Food Aggression
Toy Aggression
Fence Jumping
Escaping Yard
Digging
Separation Anxiety
Barking
Destructive
Chewing
Scared of Storms
Finicky Eater
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What is the temperament of dog towards Humans? (Please check all that apply)
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Friendly
Shy
Cautions
Outgoing
Hyper
Energetic
Calm
Anxious
Dominate
Submissive
Obedient
Challenging
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What is the temperament of dog towards other dogs? (Please check all that apply)
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Friendly
Shy
Cautions
Outgoing
Hyper
Energetic
Calm
Anxious
Dominate
Submissive
Obedient
Challenging
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Has dog ever bitten a human? If yes describe situation, location, when, seriousness of bite, etc.
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Type of Training?
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Is this dog crate trained?
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Yes
No
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Describe any behavioral problems:
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General Comments:
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Is this dog a?
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House Dog
Outdoor Dog
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Has the dog ever been (Please select all that apply)
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Abused
Neglected
Hit By Car
Bred
Allowed on Furniture
Allowed to run off leash (in non-fenced yard)
Attacked by another animal
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Is dog used to wearing a collar?
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Yes
No
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What signals dog to go out?
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What words does the dog know?
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What tricks does the dog know?
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What items are you sending with the dog? (check all that apply)
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Toys
Food and/or Bowl(s)
Collar/Tags/Leash
Crate
Bed
Clothes
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Are you sending any medication with the dog? If so, what are you sending along?
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Please be advised we will want to speak with your
veterinarian. Please contract your veterinarian to let him/her
know we will be calling and that you authorize the veterinarian
to release all records of your dog to us. By checking yes you
agree to contact your veterinarian. |
Yes
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By checking this box you understand the we reserve the right to refuse or deny any application.
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Yes
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By signing this form, I hereby swear that the above
information is true and complete to the best of my knowledge and
ability about the above said dog. I understand that the dog will
be further evaluated by Chihuahua & Small Dog Rescue, Inc. to
determine whether we will accept the dog. |
Yes
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Please attach a picture of this dog.
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Signature
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Date:
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