Please provide as much information as possible, so that we can find the appropriate home for your dog.  Above all, please be honest.  Please answer all questions.  If the question does not apply to your dog answer N/A.

Dog Information

Dogs Name:

Age:    Weight:    Is the dog Spayed/Neutered?  Yes   No 

Where did you get this dog?

How long have you had this dog? 

Is it a purebred:  Yes  No  I don't know        Do you have AKC papers?  Yes No I don't know

Is the Pedigree available? Yes No I don't know

 Are vaccinations current?  Yes No I don't know

Veterinarian Name 

Veterinarian Address: 

Is the dog on heartworm preventative?  Yes No I don't know

If Yes, what brand and when last given:

Has this dog ever had a seizure:  Yes No I don't know

If Yes, how often does the dog have seizures?

If Yes, what medication is the dog on for seizures?

List any orthopedic problems such as hip dysplasia, arthritis, stiffness or difficulty moving around:

Condition of skin-any allergies? Yes No I don't know

Please list any other medical conditions:

Behavior Assessment

What is your dogs disposition?

Is this dog confident or shy?

Can you? (Check if yes)  Take food away?  Take toys away? Take bones away?

 Does your dog? (Check if yes) Dig?  Chew? Escape from yard? Escape from the house Jump on people?

Ride well in cars? Swim? Run away? Jump fences? Bark a lot? Steal food/items off counters or tables?

Afraid of thunderstorms?

If Yes, what does this dog do during a thunderstorm?

Is this an inside or outside dog? Yes No

Is this dog housebroken? Yes No I don't know

Is this dog crate trained? Yes No I don't know  

Does this dog get along with: Children Yes No  Other dogs? Yes No  Cats? Yes No

Other animals? Yes No

Is this dog aggressive towards other dogs? Yes No

If Yes, what did the dog do to make you think it didn't like the other dog?

Is the dog possessive over food dish? Yes No I don't know

Has your dog ever lived with children? Yes No

If yes, for how long? What were/are their ages?

How did the children treat the dog?

Does the dog accept: Strangers? Yes No Men? Yes No Women? Yes No

Is there anywhere the dog does not like to be touched?

Has your dog ever growled at or bit a person? Yes No

Has your dog ever growled at or bit another animal such as a dog or cat? Yes No

Has your dog displayed any other signs of aggression? Pleas describe or enter N/A

Does the dog like to grab your arm or clothes (mouthy)? Yes No

If yes, explain:

Does your dog like to chase bikes or cars? Yes No

What does your dog dislike?

Has this dog been to obedience school? Yes No

Does this dog know any commands? Please list:

What are your training methods? Please describe:

Have you ever disciplined your dog when he/she has done something wrong?  Please describe:

Home Environment Assessment

Has your dog ever lived with: Other dogs? Yes No Cats? Yes No

How do you exercise your dog?

Is your dog use to being home alone during the day? Yes No

If Yes, how many hours?

Does your dog have separation anxiety? Yes No

What kind of food and supplements is your dog on?

What are your dogs good points?

What are your dogs bad points?

Please bring this form and any other paperwork (veterinary records, AKC papers etc.) you may have when surrendering you dog to us.