Intake Form
Email *
Your answer
Dog *
Name
Your answer
Gender
Spay/neutered
Micro - Chipped
Age
Your answer
Birth date
if known
Your answer
Weight (lbs)
Your answer
Color
Your answer
Breed
Your answer
Relinquishing Owner
Name
Your answer
Email
Your answer
Home phone
Your answer
Cell phone
Your answer
Street address
Your answer
City
Your answer
County
Your answer
State
Your answer
Zip
Your answer
Affiliation
Reason for relinquishment
Your answer
Clinic Info
Name of vet
Your answer
Name of clinic
Your answer
Phone number
Your answer
Address
Your answer
City, State, Zip
Your answer
Date of last vet visit
Your answer
Health & Diet
What type of food
wet, kibble, and brand
Your answer
Heartworm preventative?
Does this basset have any of the following?
If yes, explain
Your answer
If yes, explain
Your answer
Other health issues
If yes, explain current health issues
Your answer
Current Lifestyle
Where does the dog live?
Where is the dog kept when alone?
Your answer
How many hours is the dog alone each day?
Your answer
Where does the dog sleep during the day?
Your answer
Where does the dog sleep during the night?
Your answer
Where does the dog eliminate?
Does the dog go for walks?
Can the dog handle stairs?
Family Members
Number of adults
Your answer
Children
Number of boys (less than 18 yrs in the household)
Your answer
Ages of boys in household
Your answer
Number of girls (less than 18 yrs in the household)
Your answer
Ages of girls in the household
Your answer
Other Animals
Number of dogs
Your answer
Breed(s)
Your answer
Number of cats
Your answer
Other pets?
hamster(s), snake(s), rabbit(s), etc.
Your answer
Temperament
General behavior assessment
Your answer
Dog Habits
Aggressive behavior
Fears
thunderstorms, vacuum, etc
Good with children
Good with dogs
Good with cats
Afraid of men
Afraid of woman
Logistics
How soon does the dog need to be moved?
Your answer
Can caller assist with transport?
Your answer
Comments
distance willing to travel, availability, etc
Your answer
Action
Your answer
Additional comments
Your answer
Confirm that you're a real person
(The color of grass)
Your answer
Submit
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