Your name
Home Address (no PO boxes, please)
City, State, Zip
Home Phone
Cell Phone (if none, enter NONE)
Work Phone (if none, enter NONE)
Email address
Name of dog
Is this dog yours or one you found?
How long have you had this dog?
Breed(s)
Is this dog purebred?
Select One
Yes
No
Age (or closest guess)
Sex
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Male
Female
Color(s)
Coat length
Weight (estimate if necessary)
Housebroken?
Select One
Yes
No
Not sure
Crate trained?
Select One
Yes
No
Not sure
Inside or outside dog?
Select One
Inside
Outside
Both
Gets along with other dogs?
Select One
Yes
No
Not sure
Gets along with cats?
Select One
Yes
No
Not sure
Gets along with children under 5?
Select One
Yes
No
Not sure
Gets along with children over 5?
Select One
Yes
No
Not sure
Walks nicely on a leash?
Select One
Yes
No
Not sure
How does this dog react when left alone? (ie: separation anxiety, destructive, etc.)
How many hours per day/week is this dog used to spending alone?
Is this dog a known barker?
Select One
Yes
No
Not sure
Is this dog a known digger?
Select One
Yes
No
Not sure
Is this dog afraid of anything in particular? (ie: men, brooms, thunder, etc.)
Does this dog like to ride in the car?
Select One
Yes
No
Not sure
Describe any training this dog has had, or tricks it has learned
Does this dog exhibit any of the following behaviors?
If Other, describe:
Has this dog EVER bitten another animal?
Select One
Yes
No
Not sure
If Yes, under what circumstances? Explain completely
Has this dog EVER bitten a person?
Select One
Yes
No
Not sure
If Yes, under what circumstances? Explain completely
Where did you find the dog, or if you own it, where did this dog originally come from?
If this was a stray, was this dog wearing a collar? Tags? Have a tattoo? Was this dog scanned for a microchip? Please describe in detail.
If a stray, what steps have you taken to find the owners? Please check all that apply:
If Other, describe:
If this is your dog, what steps have you taken to re-home him/her? Please check all that apply:
If Other, describe:
Why does this dog need to be rehomed? Please check all that apply:
If Other, describe:
If this is your dog, what steps have you taken to resolve the problem without rehoming? What can we do which might help you keep the dog?
Is this dog spayed or neutered(fixed)?
Select One
Yes
No
Not sure
Is this dog microchipped?
Select One
Yes
No
Not sure
If Yes, with what company (eg. Avid, HomeAgain)
If yes, will you provide necessary paperwork and/or permission in writing for
the microchip company to change ownership information over to DPS or a DPS representative?
Select One
Yes
No
Is this dog up-to-date on vaccinations?
Select One
Yes
No
Not sure
If yes, which vaccines? Please check all that apply:
If other, describe:
Has this dog had a fecal float recently (to test for internal parasites such as worms)?
Select One
Yes
No
Date and results of last heartworm test:
Brand of flea/tick prevention (or NONE if the dog is not on any)
Name and phone number of this dog's vet
Date of last vet visit
Can you provide all pertinent medical paperwork on this dog? (ie: certificate of sterility, proof of vaccinations, etc.)
Select One
Yes
No
Please list all medications that this dog is currently taking, and the reason(s):
What is this dog's physical health and condition? Please describe ANY known health problems completely:
How much are you willing and able to contribute financially toward medical care and/or
boarding/general care for this dog at the time of relinquishment?
How long can this dog safely stay where he is?
Please provide any other additional information that will be useful/helpful to us that is not already covered in this form:
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