Staff Member Assisting

Canine or Feline?

Canine Feline

Pet’s Name

Pet’s ID Number

Your Name

Home Phone

Work Phone

Email Address

Street Address

City

State

Zip Code

Time at this Address

Own or Rent

Own Rent

Landlord’s Name

Apartment

Yes No

Landlord’s Tel #

Do you have a completely secure fenced yard?

Yes No

How high is it?

Will this pet be chained up?

Yes No

Will this pet be kept in a dog run?

Yes No

Dog run dimensions

Do you have a pool?

Yes No

Is the pool fenced?

Yes No

Type of pool fence

Height of pool fence

Dogs require time for training.  Do you have the time and are you willing to train and deal with behavior problems, i.e. diggin, chewing, jumping, etc?

Yes No

Have you owned a pet before?

Yes No

Where did you get it?

What other pets do you have in your home now?

What other pets have you owned in the last 5 yrs?

What are the names of the other pets?

What are their ages?

Was a pet ever given away?

Yes No

Why given away?

How many children are in the home?

Their ages

Where will this new pet will be kept?

Indoors Outdoors Both In & Out

Where will this pet sleep?

Indoors Outdoors

Who is your veterinarian?

Veterinarian Tel #

Under what name are your pet’s records listed at your veterinarian?

How long will the pet be left alone during the day?

Can you afford food?

Yes No

Can you afford veterinary care?

Yes No

Can you afford grooming?

Yes No

Is anyone living in your home allergic to pets?

Yes No

Have your current/previous pets been spayed/neutered?

Yes No

If no, why?