I, the owner, certify that I am the guardian of this animal,
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TYPE YOUR (OWNER) FIRST AND LAST NAME BELOW
First Name
Last Name
Who is a
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DESCRIPTION OF DOG BELOW, COLOR, BREED, WEIGHT, AGE, SEX, ETC
Today's Date
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MM
DD
YYYY
Your address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
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Your Phone Number
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(###)
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Where did you get this dog?
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How long have you owned this dog?
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Why is the dog being given up?
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What is the name, phone and address of the veterinarian who lasted treated and vaccinated this dog?
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The following questions will be of help to the person who will adopt your dog. If there is anything you would like to add that may make your pet's adjustment to a new home easier, please feel free to share that information below.
Check the words that best describe your dog.
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Is the dog currently on vaccinations?
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Yes
No
If yes, please list the dates of vaccinations.
RABIES
MM
DD
YYYY
DHLPP
MM
DD
YYYY
BORDATELLA
MM
DD
YYYY
LEPTO
MM
DD
YYYY
Date of last heartworm test?
MM
DD
YYYY
Heartworm test was:
Negative
Positive
Is the dog on heartworm preventative?
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Yes
No
Brand of heartworm medication?
Date of last pill?
MM
DD
YYYY
Is the dog spayed or neutered?
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Yes
No
Has the dog been previously bred?
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Yes
No
Date of last fecal exam for parasites?
MM
DD
YYYY
Fecal exam results?
Negative
Positive
If positive, was the dog treated?
Yes
No
Please list medications your dog is taking:
Is your dog housebroken?
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Yes
No
Partly
If partly, please describe when/where accidents occur:
Are there any behavior problems?
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Yes
No
If yes, please describe in as much detail as possible
Please elaborate on your dogs interactions with other dogs in detail. Has your dog lived with other dogs? Have dog friends? Good with big dogs, small dogs, exuberant dogs, shy dogs? Has your dog gone to dog parks? Is your dog leash-reactive? Please be as detailed as possible and as honest as possible so we can help your dog.
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Does your dog have handling sensitivities? How is your dog meeting strangers?
Does the dog like children?
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Yes
No
Are there children in the home?
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Yes
No
What are their ages?
What BRAND of dog food is the dog fed?
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How many cups is the dog fed?
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How many times per day is the dog fed?
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Any specific feeding instructions you would care to share with your dogs new owner?
Where does the dog sleep?
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Is the dog allowed on your furniture?
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Yes
No
Is the dog crate trained?
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Yes
No
How does the dog react to being left alone?
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Please list any particular fears your dog has.
Desrcibe any training the dog has, tricks it knows, and any experience with a trainer.
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Does the dog have any known health problems?
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Yes
No
If yes, please describe
Does the dog like riding in the car?
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Yes
No
What is the dog's favorite
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toy or plaything?
What does the dog like?
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What does the dog dislike?
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Does the dog jump kiddie gates or fences?
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Yes
No
If yes, how high is the dog able to jump?
Is the dog a digger?
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Yes
No
Is there anything else you can share that is special, unusual, or endearing about your dog that will help the new owners?
Are there any things you think a new owner needs to know?
Please describe a typical day for your dog during the workweek (what time wake up, when eat, how many walks a day, where to -- dog parks, trails, neighborhoods, runs, etc), how long left home alone, what time to bed?
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Please provide a summary of the “ideal” home for your dog:
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By checking the box below, I agree that the following information I have provided is true & accurate to the best of my knowledge.
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