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Pitties.Love.Peace Intake Questionnaire
The answers to the following questions will assist us in placing your dog in a compatible foster home and finding a suitable, loving adoptive home. Please answer all questions thoroughly and to the best of your knowledge. NOTE: We cannot guarantee that we will be able to take every dog. We must have a compatible foster home and that is determined partly by the information you provide.
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Email
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Your email
Owner name:
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Your answer
Street address:
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Your answer
City, state, and zip code
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PLEASE NOTE: Pitties.Love.Peace is located in central Pennsylvania. Dogs must be able to be transported to us in order to be considered for placement.
Your answer
Phone number:
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Your answer
Alternate phone:
Your answer
Email address:
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Your answer
DOG INFORMATION
Dog's name:
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Your answer
Dog's gender:
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Female
Male
Dog's age:
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Your answer
Dog's Breed:
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Your answer
Date of birth, if known:
MM
/
DD
/
YYYY
Where did you obtain the dog?
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Your answer
How long have you owned the dog?
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Your answer
Why do you need to surrender the dog?
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Your answer
HEALTH INFORMATION
Is the dog up to date on vaccinations?
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Yes
No
Please list the name, address, and phone number of the veterinarian who last treated this dog:
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Your answer
Is the dog spayed/neutered?
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Yes
No
Is the dog microchipped?
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Yes
No
Does the dog have any chronic/ongoing medical conditions or a history of any injury?
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Yes
No
If yes to the above, please explain:
Your answer
Does the dog have any known allergies?
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Yes
No
If yes to the above, please explain:
Your answer
Please list any medications the dog is currently taking:
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Your answer
GENERAL INFORMATION
Is the dog house-trained?
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Yes
No
Does the dog do well with the following? Please check all that apply.
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All dogs
Large dogs
Small dogs
Cats
Small animals
Small children
Men
Women
Required
Does the dog live in a multiple dog household?
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Yes
No
Is the dog crate trained?
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Yes
No
If no to the above, where does the dog stay when left home alone? How does he/she react to that?
Your answer
Does the dog know any basic commands?
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Yes
No
If yes to the above, please list the commands:
Your answer
Has the dog had or attended any formal training or obedience classes?
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Yes
No
If yes to the above please list the type of training:
Your answer
Has the dog ever shown aggression towards people or other animals?
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Yes
No
If yes to the above, please explain:
Your answer
Has the dog ever reacted poorly to sharing toys/bones/food with humans or other pets?
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Yes
No
If yes to the above, please explain:
Your answer
Is the dog fearful or intolerant of any of the following? Please check all that apply.
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Loud noises
Thunder
Sudden movements
Strangers
Traveling in the car
Vet's office
Bathing
Nail trimming
Ear cleaning
Being confined
None of the above
Other:
Required
For any checked responses above, please describe the reaction to each.
Your answer
Is the dog hand shy or timid?
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Yes
No
Please list any undesirable habits or behaviors we can work on with the dog, such as excessive barking, fence jumping, chewing, leash pulling, separation anxiety, etc:
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Your answer
If we are able to accept your dog into rescue, what are some things you would like us to know in addition to the above questions? (The more information provided, the easier it will be for us to determine if we can continue to care for your dog as he/she deserves.)
*
Your answer
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