House of Paws Dog Rescue
Kannapolis, North Carolina 28083

First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Work Phone
x

Cell Phone

Alt Email

What is your pet(s) name(s)?*

What is your dogs age and breed?*

What is your dogs sex?*
Choose one: Male Female Male Neutered Female Spayed

Are your dogs vaccines up to date?*
Choose one: Yes No

Does your dog have any medical issues?*
Choose one: Yes No

Has your dog been diagnosed with any of the following conditions? Check all that apply.
Choose all that apply: Upper respiratory infection Epilepsy or Seizures Diabetes Thyroid Disease Allergies Organ Failure Heart Murmur Urinary Tract Infection Tumors Other

If other, please explain further

Is your dog currently given any medications?*
Choose one: Yes No

If yes, what medications?

Please list all animals in the household: (name, species, breed, sex, age obtained, age now)

Please list all people in the household (include ages of all children) (name, age, hours away from home, relationship)*

Why did you decide to acquire this dog?*
Choose one: Companion For child For protection

How did you acquire your dog?*
Choose one: Shelter/rescue Internet Friend Found/stray Other

If other, please explain further

Has the dog had previous owners?*
Choose one: Yes No

If yes, explain why given up

Do you use a crate?*
Choose one: Yes No

If yes, when did you begin to crate your dog?

Does your dog have accidents in the home?*
Choose one: Yes No

If so, how often?

How long is your dog alone each day?*

What type of play does your dog enjoy? (ex: ball, chase tug, none)*

What do you think is your dogs most undesirable behavior?*

Does your dog know any tricks?*
Choose one: Yes No

What type of training has your dog had? (trained at home, private trainer, etc?)*

Does your dog exhibit any of the following behavior problems? (Select all that apply)
Choose all that apply: House Soiling Stool eating Destructiveness Jumping Up Mouthing on hands/clothing Chase cars, people, etc. Stealing (Objects, Food) Humping, Roaming Compulsive habits (Paw Licking, etc.) Fearful (Shy/Phobic Reactions) Excessive excitability Sleep Problems Aggression to People Aggression to Dogs Aggression to cats/small animals Barks at you/family Barks at strangers

Is there any thing else House of Paws Dog Rescue needs to know about your dog?

***This form will be signed and dated upon official surrender of your pet.

I, _________________________________, am signing over any and all rights of ownership of (Pet(s) Name(s)) _________________________ to House of Paws Dog Rescue. .

Print Name______________________________________________

Sign Name _____________________________________________

Date _______________________________ 

House of Paws Representative Print Name

_______________________________________________________

House of Paws Representative Sign Name

______________________________________________________

Date__________________________________________________