First Name
Last Name
Address
City
State/Province
Zip/Postal Code
County
Email
Home Phone
Cell Phone
Alt Email
General Info
Animal's Name
Please Include a description of the animal, i.e. breed, color, and markings
Age
Date of Birth
Sex
Male
Female
Please tell us the approximate weight of your animal
Is the animal spayed/neutered
Yes
No
How long have you owned this animal
Where did you get this animal
Craigslist
Breeder
Friend/Family
Newspaper
Ad
Pet
Store
Stray
Shelter
Other
Please explain the reason for surrendering the animal
Is the animal housebroken/litter box
Yes
No
Animal History
Is the animal is friendly with (please check all that apply)
Adults
Men
Women
Children(under 5 years)
Children(over 5 years)
Strangers
Dogs
Cats
Has this animal ever attacked another animal or human
Yes
No
If you answered yes to the question above, please explain
Do you consider the animal to be protective
Yes
No
Has the animal ever bitten anyone or shown other signs of aggression
Yes
No
Has the animal received any obedience training
Yes
No
Can or does the animal jump or climb fences
Yes
No
Can this animal be trusted by itself inside for extended periods of time
Yes
No
Is the animal kennel/crate trained
Yes
No
Unknown
Where is the animal primarily kept
How often and what kind of exercise does the animal get
What type and brand of food is the animal currently eating
Any food it can not eat
Select the commands the animal knows(check all that apply)
Sit
Stay
Down
Heel
Come
Other commands
Please describe the animals good and bad habits
Animal Health History
Is the animal currently under veterinary care
Please enter the primary vet's name, phone number and address
Do you agree to the provide us with all information (including vet records) needed to take you animal into our shelter
Yes
No
When did the animal last receive a rabies vaccination (note if 1 or 3 year vaccination)
DHLPP (distemper/parvo) (note if 1 or 3 year vaccination)
Heartworm test (positive/negative)
Bordetella (kennel cough)
Worming
Is the animal currently taking heartworm preventative?
Yes
No
Is anything being used for flea/tick preventative?
Yes
No
Does the animal have any of the following? (check all that apply)
Heart Problems
Skin Problems
Allergies
Diabetes
Eye Problems
Dental Problems
Respiratory Problems
Digestive Problems
Hepatitis
Muscular Disease
Hip Problems
Cancer
Other
If you selected other from the list above, please explain
Are you aware of any other medical or behavioral problems that would be important to someone interested in adopting this animal?
Submit