Tysor Veterinary Clinic

*All fields in red are required

Are you over 21?
Name:
Address:
City:
State:
Zip Code:
Phone:
Work Phone:
Cell Phone:
Email:
Name of pet(s) you are interested in:
What is it about this specific pet that appealed to you?
How did you hear about us?
ABOUT YOUR HOUSEHOLD
Do you have children or grandchildren who live with you?	Yes No
Number of children
Childrens' ages:
Please list other residents in your household:
Are all the pets present in your household up to date on their vaccinations?	Yes No
Are ALL household members in complete agreement in adopting/caring for the dog?	Yes No
Do any of your family members have allergies?	Yes No
ABOUT YOUR HOME
Are you willing to have a representative from our organization visit your home prior to and/or following adoption?	Yes No
What type of home do you live in?	If Other-
How long have you lived at your present address?	Years Months
If you rent, do you have the permission of your landlord to keep a dog?	Yes No
Your landlord's name:
Your landlord's phone:
May we have permission to contact your landlord?	Yes No
Do you have a doggie door?	Yes No
Do you have a fenced yard?	Yes No
Please describe the fencing:	If other-
YOUR EXPERIENCE WITH PETS
I consider myself:
Please describe any pets you currently have:
Are ALL current pets spayed/neutered?	Yes No
If you owned a dog before, what happened to your previous dog(s)?
If your previous pet(s) died, give age and cause of death:
Have you ever had to relinquish a dog?	Yes No
If yes, what were the circumstances?
If you have current pets, or have owned a pet before, may we contact your veterinarian?	Yes No
Veterinarian name:
Veterinarian phone:
Please provide at least one other reference. Name:
Reference phone:
Reference relationship to you:
CARING FOR YOUR DOG
Who will be the primary caretaker of your dog?
How long are you gone each day?
Where will the dog sleep at night?
Where will the dog be housed during the day when you are home?
Where will the dog stay while you are gone during the day?
How often do you travel?
When you travel, who will care for the dog?
How will you exercise the dog?
How much adult supervision of dog and child will be provided?
With neighborhood children?
How much responsibility will your child/children be given in the care of the dog?
What kind of obedience training do you intend to give to your dog?
Are you willing to take your dog to a veterinarian for an annual physical and vaccinations?	Yes No
Are you willing to have your dog tested annually for heartworms and provide monthly heartworm prevention?	Yes No
Are you willing to provide regular flea/tick control?	Yes No
A DAY IN THE LIFE...
Describe what a typical day will be like for this pet if he/she is adopted by you:

COMMENTS

GENERAL AGREEMENT: All of the information I have given is true and complete. I understand that Tysor Veterinary Clinic has the right to refuse my application.