Important: Please Read The Surrender Process Before Filling Out This Intake Form

Dog's Name:
Age:
Date of Birth (If Known):
Sex:
Color of Dog: Fawn
Brindle
White
Is your dog?
Owners Name:
Email Address:
Address:
Home Phone Number:
Work Phone Number:
Cell Phone Number:
Veterinarian(s) Name, Address, & Telephone:
Find A Home By (Date):
Reason for Surrender:
Is the dog? Spayed
Neutered
Not Spayed Or Neutered
Has the dog been bred? Yes
No
Has the dog been injured? Yes
No
If Yes, Please Explain:
Does the dog have any known medical conditions, including allergies? If Yes, please list:
Is the dog current on shots? Yes
No
Please list the names and ages of all adults living with the dog:
Please list the names and ages of all kids living with the dog:
Where does the dog live? Urban
Rural
Suburban
Farm
Does the dog live in?
Where does the dog sleep (Check All That Apply): Dog Bed
Cellar/Basement
Couch
Owners Bed
Crate
Floor
Outside
Is the dog aggressive towards people? Yes
No
If Yes, Please Explain:
Does the dog tolerate small children? Yes
No
I Don't Know
Does the dog tolerate other dogs? Yes
No
I Don't Know
Does the dog tolerate cats? Yes
No
I Don't Know
Is the dog an only dog or in a multiple dog household? Only
Multiple
List Age, Sex, Type of other Dogs/Cats in household:
How many hours is the dog used to being left alone during a typical day: 8 Or More Hours
6-8 Hours
6 Hours Or Less
Occasional Brief Periods
Is the dog housebroken? Yes
No
Some Accidents
Frequent Accidents
Is the dog crate trained? Yes
No
Does the dog enjoy exercise? Yes
No
How did you most often exercise the dog (Check All That Apply): Leash Walks
Jog With Owner
Fenced Yard
Throw Stick
Play With Toys
Dog Park
Dog Is A Couch Potato
Does the dog tolerate being touched in the following places
(Check All That Apply): 		Tail
Belly
Feet
Head
Ears
Please describe the temperament of the dog:
Does the dog enjoy car rides? Yes
No
Short Rides Only
Is the dog hand shy? Yes
No
Does the dog spook easily? Yes
No
Is the dog afraid of
(Check All That Apply): 		Loud Noises
Veterinarian
Broom
Cars
Men
Vacuum
Thunder
People In Uniform
Dogs behavioral habits
(Check All That Apply): 		Chews Furniture/Clothing
Bites
Digs Holes
Jumps Fences
Separation Anxiety
Barks Excessively
Comments:
Please upload as many pictures as possible (It helps to speed up the process):
Picture #2:
Picture #3:
Picture #4:

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