Dog Information
Pet's Name:
Registration papers included:
Choose One
Yes
No
Sex:
Approx. Weight:
Age:
Date Of Birth:
Microchip Registration:
What type of food is the dog being
fed?
How much?
Dog's Living Situation
Where does the dog spend the day?
Where does the dog spend the night?
How many hours on average does the dog spend
alone weekdays (without humans)?
How many hours on average does the dog spend
alone weekends (without humans)?
Personality
Housebroken?
Yes
No
Has Occasional Problems
Unknown
If this dog has
occasional housebreaking problems, explain when and why:
Crate-trained?
Yes
No
Unknown
Get along with other dogs?
Yes
No
Unknown
Get along with cats?
Yes
No
Unknown
Good with children?
Yes
No
Unknown
Protective of food with other dogs?
Yes
No
Unknown
Protective of food with people?
Yes
No
Unknown
Walk nicely on leash?
Yes
No
Unknown
Like to ride in the car?
Yes
No
Unknown
Favorite toys/games:
Like baths?
Yes
No
Unknown
Special grooming likes/dislikes:
Knows the following commands:
Does the dog do any of the following:
Describe the general behavior/temperament of
this dog:
It is important that you list any and all behavioral
problems. We want your dog to go to a good, permanent and loving
home. To do this, we need to know as much about its good and bad
traits as possible. List all bad habits/behavior concerns:
Has this dog bitten any human?
Yes
No
Unknown
If yes, who and under what
circumstance:
Has this dog bitten any animal?
Yes
No
Unknown
If yes, who and under what
circumstance:
Health Information
Indicate date of most recent
vaccination/test:
Rabies:
Distemper Combination:
Bordatella:
Lyme:
Heartworm test:
Type of heartworm pill:
Current supply sent with dog?
Choose One
Yes
No
Is this dog spayed/neutered?
Choose One
Yes
No
Date of spay/neuter:
Does the dog have any known medical problems?
Does the dog require medication for any temporary
or ongoing problem?
Yes
No
Unknown
If yes, explain:
Can you provide veterinary records?
Yes
No
Unknown
Veterinarian
First Name:
Last Name:
Organization:
Address:
City:
State:
Zip:
Telephone Number:
Do you hereby authorize any veterinarian or employee
from the practice named above to release any information and records
concerning your pet's medical records to whomever may present this
application, in person, by mail or fax?
Choose One
Yes
No
Origination Information
Where did you get the dog?
Registration papers included:
Choose One
Yes
No
Has the dog had other owners?
How many?
Why did the previous owners give the dog up?
Rehoming Information
Do you certify that you are the legal owner of
this dog and have the authority to place him/her into rescue?
Choose One
Yes
No
Name of owner:
Address:
City:
State:
Zip:
Telephone Number:
Email:
How long have you had this dog?
What is the reason you need to give up this dog?
Please indicate the time frame in which you need
to give up your dog?
(How long can the dog be maintained
until a rescue volunteer needs to take possession?)
Other Information
For our records, please tell us how you found
out about our Rescue:
Agreement
By pressing the SUBMIT button, you attest
that all of the information you have provided in this application
is true and correct.
Please do not hit the SUBMIT button more
than once. You will receive a confirmation page when your form
has been processed and saved on the web server!
If you have any problems submitting this
form please email us and make sure you describe what happened.
You can also print out your application and mail it to: Tidewater
Bichon Frise Rescue, Inc., P.O. Box 8084, Suffolk, VA 23438
