Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Dog's name

Breed

Coat color

Age

Weight

Male/Female

Age of dog when obtained

Microchip Company and Number

is the dog primarily a house dog, outdoor dog, or both

Is the dog housebroken? If not please explain

Can the dog be trusted to stay by itself in the house for extended periods of time

Does the dog jump fences, if yes, how high?

Has the dog been kept on a tether indoors or outdoors

Where does the dog sleep at night

When and where is the dog fed

What brand of dog food does the dog eat and quantity

Name of Veterinarian and Clinic

Vet Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Vet Phone

(###)

###

####

Vet Email

Has your dog been spayed or neutered, if yes, what age

Name of vet that provided this service

Is the dog current on the rabies and distemper shots

Dates last given

Can you provide a complete vet record

Does your dog have any health issues currently, if yes, please explain

Currently on medication, if yes, list medications

Any past injuries or health concerns, if yes please explain

The owner hereby states that this dog has not bitten a human or shown unprovoked aggression towards another domestic animal.

owner's initials

Describe behaviors that may be difficult or annoying

Dog aggression, barking excessively, digging, jumping on people, marking territory, roaming, Barking at other dogs while on leash, pulling on leash, pottying in the house, cat aggression, other..

Is the dog living with other animals

if yes, what kind, how many

Does the dog get along with the animals

Age of children dog has been regularly exposed to and dog’s reaction:

Baby to 5 years

5-9

10-13

Older

Other

Does the dog have any fears or negative reactions to:

Storms

Bicycles

Cars

Firecrackers

Strangers

Vacuums

Loud noises

Certain type of people

Other

Reaction to strangers

Does the dog strongly prefers men or women

Has the dog attended obedience classes or other training

Commands the dog knows

Sit

Down/Drop

Stay

Heel

Shake

Rollover

Come

Other

Where is you get your dog

Friend

Pet shop

Gift

Stray

Breeder

Animal shelter/rescue

Abandoned

Other

The information provided above is accurate and current.

Date