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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