Owner Surrender Intake Form - Dog printable pdf download

Owner Surrender Intake Form (Dog)

OPERATION PETS ALIVE!

Please take the time to answer each of these questions to the best

of your ability. We want to find your pet a good forever home as

quickly as possible. ANY information is important! Please answer

thoroughly and honestly so we might make a good match for him.

Thank you Operation Pets Alive volunteers.

Owner Name____________________________________________________________

City, State, Zip__________________________________________________________

Email___________________ Home Phone_______________Cell__________________

Work____________________

DESCRIPTION of DOG:

Name_________________________________ Sex____________ Age____________

Breed if known:____________________ Mother____________ Father_____________

Color__________________ Weight________________

AKC papers and/or pedigree if available_______________________________________

MEDICAL HISTORY:

List any known medical conditions__________________________________________

List any past surgeries or severe illnesses______________________________________

List all current medications or supplements ____________________________________

Heartworm preventative?_________ Date last administered_______________

Rabies Vaccine? ________Date administered________ Next one due?_____________

DHLPP Vaccine________Date administered? _______________

Bordatella?__________ Date administered?________________

Heartworm Test within last 60 days?_________ Positive________ Negative_________

May we contact your vet for any additional information?

Veterinarian Name______________________ Address____________________

Phone?____________________________

When was your last visit to your vet and for what reason?_________________________

INFORMATION FOR NEW HOME

Does your pet live mostly indoors or outdoors or both?__________________________

Where does your pet sleep?_________________What type of bed?________________

What food has your pet been eating?________________ How often?______________

How much?___________________________________

Housebroken? Completely? ___________Partically?________ Not at all?_______

OK in a crate?______ Walks well on a leash?________ Travels well in a car?________

Knows some commands? Sit?____ Stay?___ Down?___ Come?___ Any other command

or “tricks”?____________________________________________________________

Owner Surrender Intake Form - Dog