Intake Profile Form

"*" indicates required fields

Surrendering Party's Information

Name*

First Last

Email*

Enter Email Confirm Email

Phone*

Basic Information

Dog's Name*

Age or Date of Birth*

Sex*

When did you acquire this dog?*

Where was this dog acquired?*

Age of dog at acquisition?*

Breeder/Shelter/Previous Owner's Name/Contact Information

Description of the dog*

Reason for surrendering*

Is this dog microchipped?*

Yes

Microchip

Supplier*

Microchip number*

Registrant's name

(if known)

First Last

Registrant's address

(if known)

Street Address City State ZIP Code

Health

Select all applicable health conditions of the dog.

Please list all other health conditions.*

Routine

Feeding frequency*

Once daily

Twice daily

Other

Meal time(s)

Brand of dog food*

Amount of food fed at each meal*

List any commands this dog knows.

Describe the dog's daytime environment.*

Describe the dog's nighttime environment, including sleep location.*

Behavior

Bite history

This dog has bitten a person.

This bite has occurred within the last 10 days.

Please describe the bite situation.*

Things the dog likes

Things the dog dislikes

List any helpful information for new owners.

Select all that apply

Comments

This field is for validation purposes and should be left unchanged.