Pet Intake Questionnaire Details

Please fill out this form to the best of your knowledge. Providing we are able to assist you, your answers will help us get to know your pet and give us background information to enable us to place him/her in a home that best matches his/her personality and needs. Please provide us with as much information as possible and feel free to elaborate.

Owner's Information

Name(Required)

First Last

Telephone(Required)

Street Address(Required)

Street Name City State / Province / Region ZIP / Postal Code

Pets' Information – General

Pets' Name(Required)

Breed(Required)

Mixed

Aged(Required)

Gender(Required)

Male

Female

Status

Spayed/Neutered

Unaltered

How long have you had this dog?(Required)

Where did you get this dog?(Required)

Why are you surrendering this dog?(Required)

Is this dog Microchipped?(Required)

Yes

Number(Required)

Where does this dog primarily live (inside, outside, both)? Please explain:(Required)

Pets' Information – Medical

Has this dog ever bitten a person?(Required)

Yes

Please explain(Required)

Has this dog bitten anyone in the last 10 days?(Required)

Yes

Has this dog bitten another animal?(Required)

Yes

Please Describe:(Required)

Please explain(Required)

Does this dog have/had any known medical issues/conditions?(Required)

Yes

Please include any required medications:(Required)

What Veterinary Clinic do you use?

Veterinarian Phone Number

Most Recent Vaccinations

Rabies

DAPP

Bordetella

Other

Is your dog heartworm negative?

Yes

When was your dog last tested for heartworm?

Can you verify when your dog was last tested for heartworn?

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

Date of last heartworm test

Heartworm Preventative Used

Date Last Heartworm Prevention Given

Flea/Tick Preventative Used

Date Last Flea/Tick Prevention Given

Dog Information – Behavioral

Does this dog have any of the following behavioral issues? Check all that apply. Please explain each issue (Please be honest, as it lets us know what we may need to work on and will aid in helping us place him/her in the right home).

How does this dog behave around cats (if unknown, please state “unknown”):(Required)

How does this dog behave around other dogs (if unknown, please state “unknown”):(Required)

How does this dog behave around children (if unknown, please state “unknown”):(Required)

How does this dog behave around strangers (if unknown, please state “unknown”):(Required)

Dog Information – Training

Is this dog House Trained?(Required)

Yes

Crate Trained?(Required)

Yes

Has this dog been boarded in the past?(Required)

Yes

If yes, how did he/she do at the kennel?(Required)

Has this dog had formal obedience training?(Required)

Yes

Does this dog know any commands?(Required)

Yes

If yes, list commands

Can this dog be trusted to be alone for extended periods of time?(Required)

Yes

If No

Hidden

Is there any other information you’d like to provide about your pet?(Required)

Yes

Is there any other information you’d like to provide about your pet?(Required)

Please describe

I have completed this form to the best of my knowledge. I authorize Match K-9 Rescue and Rehab Inc. to obtain copies of medical records from my Veterinarian.

Owner Signature(Required)

Date(Required)

Comments

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