Dog Adoption Application

Serenity Animal Hospital Dog Adoption Application
Date *

Month Day Year
Date
Name of pet(s) that you're interested in meeting
Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Best time to call *
I am interested in a: *

Puppy 0-6m Young Dog 6 months-2years Adult Dog 2-7 Senior Dog 7+
What type of home do you live in? (house, apartment, condo, townhome, etc.) *
Landlords Name and number - if applicable, please let them know we may be calling.
Do you *

rent own live with parents
Current Employment Information *

Employed Full time Employed Part time Unemployed Retired Student
If employed, please list your employer, job title/line of work and length of time employed there
How many adults live in your home? *
How many children live in your home? *
Age of children in the home *
Does anyone in the home have a known allergy to dogs or cats? *

yes no
Please describe your household *

Active Noisy Quiet Average
My Yard - choose all that apply *

has a privacy fence has an invisible fence has an indoor area with pee pads/newspaper has a chain link fence has an outdoor run has a stationary tie-out has a dog house
Current Veterinary Hospital Name & Number. Please call the ahead of time to let them know that it's ok to release information to Serenity Animal Hospital *
Please list your current &past pets: name, breed, age, *
Are your pet(s) current on ALL vaccinations? (including DHLPCA, Rabies, Bordetella, Fecal Testing, Heartworm Test, and Canine Influenza)

yes no
Are your pet(s) spayed or neutered?

yes no
Are your pets given heartworm preventative year round? *

yes no
Are your pets given flea preventative year round? *

yes no
If you answered no to either of the last FOUR questions, please explain why
If you have every relinquished custody of a pet before, please explain why: *
I would be willing to adopt a: (select all that apply) *

Very high energy,active pet Dog that needs medication Dog that needs grooming Mellow/easy going pet dog that will run/jog with me shy dog dog that needs training very affectionate/attention seeking pet pet that needs little to no grooming
Where will your dog spend most of the day? *
Number of hours (average) that the dog will be home alone? *
Who will have primary responsibility for this pet's daily care? *
Who will have financial responsibility for this pet? *
What will happen to the pet if you go on vacation? *
If you move in the future, what will you do with the pet you are planning to adopt? *
Will you allow the dog on furniture/beds? *
Will the dog have run of the house? *
Are you aware that veterinary care could cost up to $600 per year, without any serious illness? *
Do you agree to provide regular, yearly health care by a licensed Veterinarian? *
Do you agree to keep this pet as an indoor dog? *
Do you agree to contact Serenity if you can no longer keep this pet? *
What is your preferred level of exercise with a dog? *

Couch potato Yard Exercise Short walks Long, Vigorous walks Hiking/Jogging
Do you plan to take your new dog to training? *
If no, please explain why
What will you do if the pet is destructive while left alone? *
When the dog goes outside, how do you plan to supervise it? *
What method will you use to discipline your dog? *
What would cause you to return your potential dog to us in the future? check all that apply *

biting/nipping barking medical needs marking/can't be house broken fighting with current pets counter surfing/begging chewing/destroying possessions fence jumping (over 4ft) digging separation anxiety divorce or death of spouse/partner changed my mind about having a pet kids leave home/won't be caring for pet change in health new baby new partner doesn't like the pet new job/moving loss of income NONE OF THE ABOVE
Personal References- please list the Name, Number & Relationship for 2 references *
All of the information I have given is true and complete. This pet will reside in my home as a pet. I will provide it with quality dog food, plenty of fresh water, indoor shelter, affection, annual physical examinations, vaccinations, heartworm and flea preventative from a licensed Veterinarian. *

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Serenity Animal Hospital Dog Adoption Application