First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
 - 

Email*

Cell Phone

DOG'S NAME

DOG'S BREED:

DOG'S GENDER:

DOG'S AGE COLOR

HOW LONG HAVE YOU HAD DOG?

SPAYED/NEUTERED?

WEIGHT?

IS THIS A PUREBRED? IF MIXED, WITH WHAT?

CRATE TRAINED?

HOUSE BROKEN?

CAN YOU DONATE CRATE?

IS DOG GOOD WITH SMALL DOGS? IS DOG GOOD WITH CATS?

IS DOG GOOD WITH LARGE DOGS?

IS DOG GOOD WITH KIDS?

AGE OF CHILDEN LIVING WITH DOG?

IS DOG OBEDIENCE TRAINED?

IS DOG DESTRUCTIVE?

ANY BEHAVIORAL PROBLEMS?

EXPLAIN IN DETAIL HAS THE DOG BITTEN OR ATTEMPTED TO BITE A PERSON?

PLEASE EXPLAIN IN DETAIL:

DOES DOG LIVE WITH ANY OTHER DOGS?

LIST BREED, GENDER, AGE: VETERINARIAN NAME, ADDRESS, PHONE NUMBER:

DOES DOG HAVE ANY HEALTH ISSUES?

PLEASE EXPLAIN: IS DOG CURRENT ON VACCINES?

WHAT IS DATE OF LAST SHOTS?

WHAT BRAND OF FOOD DOES THE DOG EAT?

IS THE DOG CURRENT ON HEARTWORM PREVENTATIVE?

IF NOT, HOW LONG HAS IT BEEN OFF PREVENTION?

HOW FAR WILL YOU TRANSPORT THE DOG?

HOW DID YOU OBTAIN YOUR DOG?*