INTAKE FORM - OWNER TURN IN

DATE:________________

DOG'S REGISTERED NAME: _______________________________________________________________

DOG’S CALL NAME: _______________________ AGE :___________________ COLORING: ____________

OWNER'S NAME:__________________________________________________ PHONE:___________________

ADDRESS:____________________________________________________________ ZIP______________

BREEDER:_____________________________________ AKC#:____________ SEX:_____ ALTERED_____

MICROCHIP# _____________________________________ TATOO _______________________________

HOUSEBROKEN:______ GOOD WITH CATS_______ GOOD WITH DOGS:_______ BARKER:___________

GOOD WITH CHILDREN: Y/N AGES:______________ DIGGER: _______DOG AGGRESSIVE:___________

SHOT RECORD:_______________________________________________________________________________

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VWD CHECK: ________________

VETERINARIAN: _____________________________________________________________________________

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REASON FOR RELEASE:_________________________________________________________________

OTHER COMMENTS:_____________________________________________________________________

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COSTS:________________________________________________________________________________

DISPOSITION OF DOG: __________________________________________________________________

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RESCUE AGENT :_______________________________________________________________________