DELAWARE VALLEY BICHON RESCUE TRANSFER OF OWNERSHIP FORM

Today's date: _____________________________
Owner's name: _________________________________________________________
Address: ______________________________________________________________
E-mail address: __________________________
Day phone:__________________________ evening phone: _____________________
Bichon's name: ________________________ sex: _________ age: _____________
Neutered/spayed? Yes or no: _________
Where is the bichon now? ________________________________________________
Has this animal ever bitten anyone? _________
If so, please describe circumstances surrounding incident:
_____________________________________________________________________
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Date & results of most recent heartworm test:_________________________________
Can you provide vet records? ________ Describe the overall health of the dog, including
any health problems, previous injuries, etc:
________________________________________________________________
___________________________________________________________________
Physical characteristics: (include appearance of coat, approx. weight, etc.):

Is this dog housebroken? _________ Has this dog been around children? Pls. explain:
___________________________________________________________
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Has this dog been around other pets? What type & how did they get along?
____________________________________________________________________
Can the owner provide equipment such as food, toys, etc. (no crates please!) Be specific:
____________________________________________________________________
Describe general behavior & temperament:
____________________________________________________________________
Why is this bichon being placed in rescue? ___________________________________ ____________________________________________________________________
How urgent is he/her placement? __________________________________________
How long have you owned this bichon? ____________
What were the circumstances of the purchase? _________________________________________________________
Is this dog microchipped or tattooed? ___________ Please list dates of the following:
Rabies: _____ distemper:_______ fecal: ________ heartworm test: ________
results: ________ bordatella: _________ Other: _________
Vet’s name: ____________________________________________________________
Address: _____________________________________________________________
phone #: _______________________________

Additional crucial information: _____________________________________________
____________________________________________________________________

By signing below, you signify your agreement to place your dog in rescue. Doing so relieves you of any rights regarding this dog, now and in the future. Signing also indicates that the above information is valid, to the best of your knowledge:
___________________________________________________________________ Signature Date