Description of the dog:

Dog’s Name:              Tattoo #:                

Gender:                    Spayed/Neutered:   

Age:                          Date of Birth:          

Coat Type:                Coat Colour:           

General History:

Breeder’s Name and Phone Number:  

Was the breeder contacted?            Yes No       Does the breeder want the dog back?           Yes No Can not take the dog

Has this dog ever been abused or neglected?            Yes No Unknown

How many owners has this dog had (including yourself):

Is this dog mainly indoors or outdoors:

How many hours does this dog spend alone each day?

Is this dog protective?             Yes No Unknown                                  

If yes, of whom?

Does this dog growl at strangers?              Yes No Unknown

How does he react to someone knocking at the door:

Does he know basic obedience?             Yes No Unknown      

Is he okay with Hardwood or linoleum flooring?              Yes No Uknown Other

Can he do stairs without difficulty?          Yes No Unknown Other      

Has he ever bitten or caused injury to a person or to another animal?            Yes No Unknown Other  

If yes, please provide details:

How often does this dog have potty accidents in the house?

Is this dog crate trained?            Yes No Unknown Other

Likes, Dislikes and Habits of the Dog:

Likes Male Dogs      Likes Female Dogs      Likes Men      Likes Women      Likes Cats

Likes kids under 5   Likes kids 5+              Likes Walks   Likes Toys           Likes Cars

Wears a collar         Walks well on leash   Follows kids   Digs in yard         Jumps fence

Barks when left alone indoors        Prone to barking outdoors       Barks inside at noises, etc.

Jumps up on people                        Destructive in the house         Snaps when taking treats

Guards food from people or other animals         Guards toys from people or other animals

Other:

Temperament of the dog:

Friendly        Happy-go-lucky        Anxious to please        Very trainable

Obedient      Hyper                      Outgoing                      High-energy

Reserved      Calm                       Untrainable                  Stubborn

Lethargic      Laid Back                Timid                             Reserved/Cautious

Health & Diet History of the dog:

1.  Vaccinated            Yes No Other Unknown          Date of last vaccinations:

2.  Rabies Shot              Yes No unknown Other       Date of last rabies shot:   

3.  Heartworm tested           Yes No Unknown Other     Date of last test and result:

4.  Spayed/Neutered               Yes No Unknown Other     Date of spay/neuter:

Name and phone number of your veterinarian:

What type of food is this dog used to being fed?

What time(s) is he used to being fed?

Does this dog have any ongoing medical issues?

Does this dog have any past illness or injuries?

Additional Information:

Reason for surrendering this dog:

 

Is there anything above (any “other” replies) that you would like to clarify?  Is there anything a family who wants to adopt this dog might like to know (afraid of thunder, loves to play ball, etc).  Anything you can think of that might help us better find a home for your dog.

Surrendering Person(s):

Full Name:                      Home Phone:   

Address:                        Cell Phone:      

City, Prov., PC:              Email:               

 

Please allow 4-5 days for a volunteer to get in touch with you.  If this is an emergency, please contact us at rescue@collierescuenetwork.com