Canine Intake Survey
Please complete this form to provide detailed information about the dog being surrendered or admitted. Your responses help us ensure the best care and placement for each dog.
Dog's Name
*
Dog's Age (in years)
*
Breed
*
Gender
*
Male
Female
Unknown
Is the dog spayed or neutered?
*
Yes
No
Unknown
Vaccination Status (check all that apply)
*
Rabies
Distemper/Parvo (DHPP)
Bordetella
Leptospirosis
Not Vaccinated/Unknown
Health Concerns (select all that apply)
None
Skin Issues
Ear Infections
Mobility Issues
Allergies
Other
Behavioral Assessment
*
Rows
Excellent
Good
Fair
Poor
House Training
1
2
3
4
Leash Walking
5
6
7
8
Interaction with Other Dogs
9
10
11
12
Interaction with Cats
13
14
15
16
Interaction with Children
17
18
19
20
Reason for Surrender/Intake
*
Please Select
Owner Surrender
Stray
Transferred from Another Organization
Other
Describe the dog's typical living environment
Does the dog have a history of biting or aggression?
*
Yes
No
Unknown
Contact Information of Person Surrendering or Reporting the Dog
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Submit Survey
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