Intake Date *Is this dog a stray ? *YesNoIf dog is a stray, if possible please answer any questions you can or select "unknown stray".Dog's Name *Please attach a photo dog to intake. *Choose FileNo file chosenDelete uploaded fileDog Birthday *Sex *MaleFemaleBreed *Size *Extra Small ( less than 12 lbs)Small (12 - 25 lbs)Medium (25-50 lbs)Large (50-100 lbs)Extra Large ( over 100 lbs)Is your dog spayed or neutered ? *YesNounknown strayIs your dog up to date on vaccinations ? *YesNounknown strayIs your dog have a microchip or tattooed ? *YesNounknown strayIf yes, what is the microchip/tattoo number ? *0 / 15Where did you get your dog ? *If your dog was from a breeder or another rescue, have you contacted them about surrendering ? What was their response ? *How long have you had your dog ? *0 / 30Why have you decided to surrender your dog ? *Does your dog have any health concerns? *Does your dog have any behavioral/aggression concerns ? *Has your dog ever nipped or bit ? *YesNounknown strayIf yes, when did the last incident occur ? *Briefly describe the situation *0 / 200Who was bitten ? *0 / 30Where were they bitten ? *0 / 100How large was the bite site ? *0 / 80Number of additional bites ? *0 / 50Did the person require medical attention ? *0 / 50What is the most damage your dog has ever inflicted on a person ? Did the person require medical attention ? *Have you observed any triggers for this dog’s aggression/reactivity ? *Describe any incidents with children where the dog has demonstrated warning signs or aggression, but may not have bitten. *Has your dog ever fought with another dog ? How many fights has your dog been in ? Did any of the dogs involved need to see a vet ? *Have you ever taken your dog to see a trainer ? *YesNoIf yes, what is the name of the trainer, and their company ? How long did you see this trainer ? *0 / 100If the following is done to or with your dog, how do they react?Have their collar grabbed.People handle them or interactions with peopleHow is your dog on a leash ?How is your dog with children?How is your dog with other dogs?0 / 100How is your dog with cats?How is your dog with other smaller animals?Does your dog resource guard or is reactive with food?Does your dog resource guard or have reactivity with toys??Is your dog crate trained?0 / 20Does your dog have separation anxiety?Is your dog house trained?Are there any triggers that you have found startle, scare or upset your dog ? *Are there any requirements we should look for in an adoptive home for your dog ? (i.e. needs another dog in the home) *Is there anything else you would like us to know about your dog ? *Name *Email Address *Phone *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeI understand that the animal I am intending to surrender will not be returned or adopted back to me for any reason. *YesSignature *Send Message
