First Name*
Last Name*
Address
City
State/Province
Zip/Postal Code -
Email*
Home Phone
Work Phone x
Cell Phone
What is the dog's name*
Dog age:*
Height*
Weight
Dog sex*
Color
Date acquired
Where was the dog obtained from?
Housebroken
Date of last vet visit, heartworm test, vaccines*
Date and Name of last vaccines given
Are you the dog's legal owner?*
If not, who is the legal owner
Does this dog have registration papers?
What is the temperament of the dog? Is s/he good with children, dogs, cats, etc?
Does the dog bite, or have aggression issues?
Where has the dog been kept?
Veterinarian's Name and Phone Number*
Other comments or information:
Have you ever given up a pet? If yes, please explain
Reason for giving up this animal:*
Signature: Typing your name here constitutes a true and valid signature.*
