First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County

Email*

Cell Phone*

First Name*

Name of Dog*

Is this dog a stray or owned?*
Choose one: Stray Owner Surrender

If this is not an owner surrender please describe how you have obtained this dog.

Microchipped? If yes, who is registered as the owner? *

Breed*

Color(s)*

Age*

Gender*
Choose one: Male, Neutered Male, Intact Female, Spayed Female, Intact

If your dog is a female, has she had any litters?*

What size do you consider your dog to be?*
Choose one: Toy Small Medium Large Giant

Dog's Approximate Weight*

Is your dog kept inside or outside?*
Choose one: Inside Outside Inside during the day/Outside at night Outside during the day/Inside at night

Last visit to a vet?*

Is your dog current on vaccines?*
Choose one: Yes No Unsure

Has your dog been tested for heartworms in the last 6 months, and result?*
Choose one: Yes, Negative for Heartworms Yes, Positive for Heartworms No, hasn't been tested within the last 6 months

Is your dog currently on heartworm prevention?*
Choose one: Yes No

Does your dog have any medical issues? If yes, please provide details of condition.*

How long have you owned your dog? *

Why do you wish to rehome your dog?*

Please check all boxes that apply to your dog.

Are there any children in your home? Please list ages.*

Has your dog ever bitten, snapped, broken skin or shown teeth to a human or other animal? If yes, please describe the situation. *

Has your dog been around other dogs outside your home? How does he/she interact with them?*

Has your dog been around other humans (adults and children) outside of your home? How does he/she interact with them? *

Please check any boxes below that apply to your dog.

Please use the space below to provide any other additional information you would like us to know about your dog, or to clarify any responses to the questions.