Today's Date
Email
Owner's Name
Phone Number
Is this your first visit?
Yes
No
Street Address
City, State, Zip
What is your county of residence?
Alternate Phone Number
What's your pet's name?
This animal is:
Male
Female
Is this animal spayed/neutered?
Yes
No
How old is this animal? (please use years and months)
What color/colors is your pet?
What breed is your pet? Please be specific.
Is this animal:
Owned by you
Owned by a friend or family member
Stray
HSPPR Return (within the first 14 days od adoption)
How long have you owned this animal?
How did you obtain this animal (i.e. found as stray, from a friend, born to one of my pets, adopted/rescued. etc.)? Be as specific as possible.
If your pet was adopted from another shelter or rescue agency, please include the name and phone number of the adoption source.
Have you contacted the person, shelter or rescue where the animal was acquired to return the pet to them?
Yes
No
If not, why not? If you did make contact, what was their response?
Please tell us why you need to find a new home for your pet today?
Is your pet microchippped?
Yes
No
What is your pet's microchip number? If not known, please type "unknown."
Is your pet's microchip registered to you?
Yes
No
If your pet's microchip is registered to somebody other than yourself, please provide the name and phone number of the person to whom the chip is registered.
Is this animal sick or injured right now?
Yes
No
If yes, please describe.
Have you taken this animal to a veterinarian for this illness or injury?
Yes
No
If so, please provide the name of the veterinarian or clinic.
What were the results of the visit?
Has your pet been treated for any other medical conditions?
Yes
No
If yes, please describe.
Has your pet lived with children?
Yes
No
If yes, what ages are the children?
How does your pet react to children?
Has your pet lived with other animals?
Yes
No
If yes, what please describe the other animals.
How does your pet react to other animals?
Has this animal ever bitten a person?
Yes
No
If yes, how long ago?
Please describe the incident(s) that led to the bite(s).
For Dogs only: We would like to help your pet remain a part of your family. With that in mind, would you be willing to attend a free consultation to assess your pet's behavior needs?
Yes
No
HSPPR does require a nominal fee in order to take in your pet. This fee allows us to perform vaccinations at intake that will protect the animal from common illnesses. Are you able to provide an additional donation to assist with your pet's care?
Yes
No
Where is your dog kept during the day?
Outdoors - in fenced yard
Outdoors - on tether/chain
Outdoors - in dog run
In a garage or outbuilding
Indoors - free roam of the house
Indoors - in crate
Where is your dog kept at night?
Outdoors - in fenced yard
Outdoors - on tether/chain
Outdoors - in dog run
In a garage or outbuilding
Indoors - free roam of the house
Indoors - in crate
How does your dog behave when left alone?
Does your dog regularly attempt to escape?
Yes
No
If yes, how does he/she escape?
Jumps/Climbs 4 ft fence
Jumps/Climbs 6 ft fence
Digs
Jumps out of window
Runs out front door every chance he/she gets
Claws/Chews his way out
Knows how to open door/gate
Is your dog housebroken?
Yes
No
If your dog does have accidents, please describe how often and why you believe they occur.
Is your dog crate trained?
Yes
No
When your dog is at home, how does he/she behave with other dogs in the home? (Please check all that apply)
Normal play/interactions
Chases
Mounts
Plays With
Plays Rough
Barks/Growls At
Lunges At
Avoids
Kept Separate
Fearful/Anxious
Killed
I don't have other dogs
When your dog is outside of the home, how does he/she behave with other dogs outside of the home? (Please check all that apply)
Normal play/interactions
Chases
Mounts
Plays With
Plays Rough
Barks/Growls At
Lunges At
Avoids
Kept Separate
Fearful/Anxious
Killed
I have never taken my dog out
When your dog is outside of the home, how does he/she behave with other small animals (including cats)? (Please check all that apply)
Normal play/interactions
Chases
Mounts
Plays With
Plays Rough
Barks/Growls At
Lunges At
Avoids
Kept Separate
Fearful/Anxious
Killed
I have never taken my dog out
How often do you exercise (interactive physical exercise) your dog?
Never
Once per day
2 times per day
3 times per day
4 times per day
5 times per day
Once per week
2 times per week
3 times per week
4 times per week
5 times per week
6 times per week
7 times per week
What kind of exercise (interactive physical exercise) is your dog regularly exposed to? (Please check all that apply)
None
Yard Play
Walks
Hikes
Run/Biking
Dog Park Play
Other
How long are your dog's regular exercise sessions on average?
None
Less than 15
Between 15 and 30 minutes
30 minutes
Between 30 minutes and 1 hour
1 hour
2 hours
3 hours
What other kind of regular exercise is your dog used to? (Please describe)
Send