First Name *

Last Name *

Phone *

Email *

Emergency Contact Name *

Emergency Contact Relation *

Emergency Contact Phone *

Emergency Contact Email *

Dog's Name *

Dog's Age *

Dog's Sex *

Dog's Breed(s) *

Adoption Date: *

Dog's Birth Date *

How long has your dog lived with you: *

How did you acquire your dog: *

How often is your dog left alone: *

Is your dog crate trained: *

How often do you use your crate: *

Where does your dog sleep: *

How does your dog walk on leash? *

When you walk your dog, if they see another dog, do they: *

How much exercise does your dog get each day: *

Does your dog guard resources? *

No

Yes, from humans

Yes, from other dogs

Does your dog swallow inedible items? (stuffing from a toy, paper, cardboard, tissues, paper towels, etc.) *

How does your dog feel about meeting puppies: *

How does your dog feel about meeting adult dogs: *

Veterinarian Office *

Vet Office Address *

Vet Phone *

Vet Email *

Spayed or Neutered? *

Do you plan to Spay or Neuter? *

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