GREAT DOG RESCUE NEW ENGLAND & BROCKTON ... - Bay …



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Intake Form

Surrendering Owner:

Date Form Filled Out:

• Dog’s Name:

• Breed:

• Gender:

• Age:

• Weight:

• Reason for surrender:

• Activity level:

• Favorite Activities/Likes & Dislikes:

• Living situation (inside/outside? sleeps? stays when alone?):

• Socialized with people - men, women, children:

• History with Children; their ages:

• Issues with other Dogs:

• Cat Tested:

• Housebroken:

• Crate Trained:

• Obedience Training:

• Behavioral/Training Issues (i.e. mouthy, jumpy, barking, chewing, nervous):

• Is this dog/puppy at all shy or fearful in any situations? If you answer yes then please elaborate:

• Ideal Adoptive Home:

• Health or Medical Issues:

• ANY Treatments for any medical problems- (antibiotics, surgeries, heartworm treatment, ehrlicia treatment etc.):

• Spay/Neuter date:

• Rabies vaccine date (if over 12 weeks):

• DHPP/DHLPP vaccine dates:

• 4DX test (HW, erlichia, lyme) date (dogs 6 mos and over):

• Bordetella vaccine date:

• Wormer - type and dates given:

• Heartworm preventative – type and dates given:

• Flea & Tick preventative – type and dates given:

***Please write one or two sentences that best describe what this dog/puppy’s best adoptive qualities would be for us to use in our listing. This is very helpful to us. Thank you.

Revised 10/19/11

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