Chesapeake Humane Society Form

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Assigned To:
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Workflow ID
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Case Status:* This field is required.
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A little bit about us...

The Chesapeake Humane Society is dedicated to helping the people and animals of our community. Please fill out this form to the best of your ability based on the assistance you are inquiring about. If you find yourself needing help with more than one of our programs you'll need to complete this form more than once as it is one form per program submission.
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Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
Please enter a valid phone number.
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Please provide a valid email address.* This field is required.
If you do not have an email address, please use none@none.com
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Zip Code* This field is required.
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What is your preferred contact method? * This field is required.
Please Select
Please Select
Email
Text
Call
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Demographic Information

The Chesapeake Humane Society is committed to Diversity, Equity, and Inclusion. If you are comfortable, please choose the category on the next card that best describes your race, ethnicity, or cultural background. You can choose the option, "Prefer Not To Answer".
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Please choose one.* This field is required.
Black or African American
Asian or Pacific Islander
Hispanic or LatinX
Native American or Alaskan Native
White or Caucasian
African
Middle Eastern
Multiracial or Biracial
Prefer Not To Share
My preferred ethnicity is not listed
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What is your preferred ethnicity?* This field is required.
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What age range best captures your current age?* This field is required.
Please Select
Please Select
Under 18
19-24
25-34
35-44
45-54
55-65
Over 65
Prefer Not To Share My Age
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What is your gender?* This field is required.
Please Select
Please Select
Female
Male
Gender Non-Conforming/Gender Queer
Questioning
I Don't Identify Using Gendered Constructs
Prefer Not To Share
My Preferred Identity Is Not Listed
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What is your preferred identity?* This field is required.
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Do you Identify as a person with a disability?* This field is required.
Yes I am a person with a disability
No I am not a person with a disability
Prefer Not To Share My Disability Status
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What is your preferred language?* This field is required.
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Do you have children under the age of 18?* This field is required.
Yes I have children under 18
No I do not have children under 18
Prefer Not To Share Children's Age
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Are you Employed?* This field is required.
Yes I am employed
No I am not employed
Prefer Not To Share My Employment Status
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Do you have Transportation?* This field is required.
Yes I have transportation
No I do not have transportation
Prefer Not To Share Transportation Details
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Do you have any past or current military association?* This field is required.
Yes I have past/current military association
No I do not have past/current military association
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Military Association
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Non Military Association
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What type of assistance are you needing?* This field is required.
Crisis Boarding
Pet Pantry
Other
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You picked "other", please specify what services you need
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Please explain why you need assistance at this time. * This field is required.
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Which agency referred you?
Please Select
Please Select
No referral was made
American Red Cross
For Kids
HER Shelter
Judeo-Christian Outreach Center
Samaritan House
Senior Services of Southeastern Virginia
Transitions
YWCA
Other
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Referring Agency Contact
First and Last Name
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Referring Agency Phone Number
Please enter a valid phone number.
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Referring Agency Email
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Which of these best describes your situation? Select all that apply.* This field is required.
Domestic Violence
Hospitalization/Treatment
Housing
Incarceration
Low-Income
Medical
Other Type of Situation
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You selected "Other", please describe your situation.
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What is your current housing situation?* This field is required.
Please Select
Please Select
Hotel
Shelter
With Friend/Family
Renting Home
Owns Home
Tent
Vehicle
Other Home Type
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You selected "Shelter", which one?
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You selected "Other Home Type", please specify.
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When does your pet need to have boarding?
Month
Day
Year
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How long do you believe you'll need our assistance?* This field is required.
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Are you, or a friend or family member, able to pick up the pet food from CHS?* This field is required.
Self
Friend/Family
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If you are unable to pick up your pet food, please list the name of the person who will be picking up your food.
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What type of pet food are you in need of?* This field is required.
Adult Dog - Dry
Adult Cat - Dry
Adult Dog - Canned
Adult Cat - Canned
Puppy Food
Kitten Food
Other
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You selected "Other". What type of food are you in need of?
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Case Contact Strengths:
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Case Contact Challenges:
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Pet Name* This field is required.
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Type* This field is required.
Dog
Cat
Other
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Age* This field is required.
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Weight* This field is required.
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Gender* This field is required.
Female
Female Spayed
Male
Male Neutered
Unknown
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Dog Breed
* Mixed Breed Large (>45 Lbs Fully Grown) *
* Mixed Breed Med (25-44 Lbs Fully Grown) *
* Mixed Breed Small (<25 Lbs Fully Grown) *
Affenpinscher
Affenpinscher/Mix
Aidi
Ainu
Akbash
Akbash/Mix
Akita
Akita Inu
Akita/Mix
Alano Español
Alopekis
Alpine Dachsbracke
American Bully
American Bully/Mix
Appenzeller Sennenhunde
Armant
Azawakh
Bahamian Potcake
Barbet
Basenji
Basenji/Mix
Beagle
Beagle, Kerry
Beagle/Mix
Beauceron
Beauceron/Mix
Berger Picard
Bichon Frise
Bichon Frise/Mix
Blue Heeler
Blue Heeler, American
Blue Heeler, American/Mix
Blue Lacy
Blue Lacy/Mix
Boerboel
Boerboel/Mix
Bolognese
Bolognese/Mix
Bolonka
Borzoi
Borzoi/Mix
Bouvier des Ardennes
Bouvier Des Flandres
Bouvier Des Flandres/Mix
Boxer
Boxer/Mix
Bracco Italiano
Braque Francais, Gascogne
Braque Francais, Pyrenees
Brasileiro, Fila
Brasileiro, Fila/Mix
Briard
Briard/Mix
Bull Arab
Bull Arab/Mix
Bulldog
Bulldog, Alapaha Blue Blood
Bulldog, Alapaha Blue Blood/Mix
Bulldog, American
Bulldog, American/Mix
Bulldog, Australian
Bulldog, Australian/Mix
Bulldog, British
Bulldog, British/Mix
Bulldog, English
Bulldog, English/Mix
Bulldog, French
Bulldog, French/Mix
Bulldog, Johnson
Bulldog, Johnson/Mix
Bulldog, Old English
Bulldog, Old English/Mix
Bulldog, Victorian
Bulldog, Victorian/Mix
Bulldog/Mix
Bulldogge, Banter
Bulldogge, Banter/Mix
Cambodian Razorback Dog
Canaan Dog
Canaan Dog/Mix
Canario, Presa
Canario, Presa/Mix
Cane Di Oropa
Cane Toccatore
Carolina Dog
Carolina Dog/Mix
Castro Laboreiro Dog
Catahoula Leopard Dog
Catahoula Leopard Dog/Mix
Cattle Dog
Cattle Dog, Australian
Cattle Dog, Australian (Blue Heeler)
Cattle Dog, Australian (Blue Heeler)/Mix
Cattle Dog, Australian (Red Heeler)
Cattle Dog, Australian (Red Heeler)/Mix
Cattle Dog, Azores
Cattle Dog, Smithfield
Cattle Dog/Mix
Chihuahua
Chihuahua, Long Coat
Chihuahua, Long Coat/Mix
Chihuahua, Short Coat
Chihuahua, Short Coat/Mix
Chihuahua/Mix
Chinese Crested Dog
Chinese Crested Dog/Mix
Chinese Foo Dog
Chinese Shar-Pei
Chinese Shar-Pei/Mix
Chinook
Chow Chow
Chow Chow/Mix
Cimarrón Uruguayo
Cirneco Dell'etna
Cockapoo
Cockapoo/Mix
Collie
Collie, Bearded
Collie, Bearded/Mix
Collie, Border
Collie, Border/Mix
Collie, Rough
Collie, Rough/Mix
Collie, Smooth
Collie, Smooth/Mix
Collie/Mix
Coonhound
Coonhound, American English
Coonhound, Black and Tan
Coonhound, Black and Tan/Mix
Coonhound, Bluetick
Coonhound, Bluetick/Mix
Coonhound, English
Coonhound, English/Mix
Coonhound, Redbone
Coonhound, Redbone/Mix
Coonhound, Redtick
Coonhound, Treeing Walker
Coonhound, Treeing Walker/Mix
Coonhound/Mix
Corgi
Corgi, Cardigan Welsh
Corgi, Cardigan Welsh/Mix
Corgi, Pembroke Welsh
Corgi, Pembroke Welsh/Mix
Corgi, Welsh
Corgi/Mix
Coton De Tulear
Coton De Tulear/Mix
Coyote
Coyote, Hybrid
Coyote, Hybrid/Mix
Coyote/Mix
Cur, Black Mouth
Cur, Black Mouth/Mix
Cur, Mountain
Cur, Mountain/Mix
Dachshund
Dachshund, Miniature Long Haired
Dachshund, Miniature Long Haired/Mix
Dachshund, Miniature Smooth Haired
Dachshund, Miniature Smooth Haired/Mix
Dachshund, Miniature Wire Haired
Dachshund, Miniature Wire Haired/Mix
Dachshund, Standard Long Haired
Dachshund, Standard Long Haired/Mix
Dachshund, Standard Smooth Haired
Dachshund, Standard Smooth Haired/Mix
Dachshund, Standard Wire Haired
Dachshund, Standard Wire Haired/Mix
Dachshund/Mix
Dalmatian
Dalmatian/Mix
Damchi
Danish Broholmer
Dingo
Dingo/Mix
Dogo Argentino
Dogo Argentino/Mix
Dogue De Bordeaux
Dogue de Bordeaux/Mix
Doodle/Mix
Dosa Inu
Double Doodle
Drever
Dutch Smoushond
Elkhound, Norwegian
Elkhound, Norwegian/Mix
Elkhound, Swedish
Entlebucher
Eskimo Dog
Eskimo Dog/Mix
Eskimo, American
Eskimo, American/Mix
Eskimo, Canadian
Eurasier
Feist
Feist/Mix
Fox, Hybrid
Fox, Hybrid/Mix
Fox/Mix
Foxhound
Foxhound, American
Foxhound, American/Mix
Foxhound, English
Foxhound, English/Mix
Goldendoodle
Great Dane
Great Dane/Mix
Greenland Dog
Greyhound
Greyhound, Galgo Pinscher
Greyhound, Italian
Greyhound, Italian/Mix
Greyhound/Mix
Griffon Vendeen, Briquet
Griffon Vendeen, Grand Basset
Griffon Vendeen, Petit Basset
Griffon, Belgian
Griffon, Brussels
Griffon, Brussels/Mix
Griffon, Wire-Haired Pointing
Griffon, Wire-Haired Pointing/Mix
Harrier
Havanese
Havanese/Mix
Heeler, Lancashire
Heeler, Queensland
Heeler, Queensland/Mix
Hound
Hound, Afghan
Hound, Afghan/Mix
Hound, American Blue Gascon
Hound, Basset
Hound, Basset/Mix
Hound, Bloodhound
Hound, Bloodhound/Mix
Hound, Dunker
Hound, Halden (Haldenstover)
Hound, Hygen
Hound, Ibizan
Hound, Ibizan/Mix
Hound, Irish Wolfhound
Hound, Irish Wolfhound/Mix
Hound, Pharaoh
Hound, Pharaoh/Mix
Hound, Plott
Hound, Plott/Mix
Hound, Schweizer Laufhund
Hound, Scottish Deerhound
Hound, Staghound
Hound/Mix
Hovawart
Husky
Husky, Alaskan
Husky, Alaskan/Mix
Husky, Siberian
Husky, Siberian/Mix
Husky/Mix
Italian Spinone
Japanese Chin
Japanese Chin/Mix
Jindo
Jindo, Korean
Jindo, Korean/Mix
Kai Dog
Kai Dog/Mix
Karakachan
Karelian Bear Dog
Karelian Bear Dog/Mix
Keeshond
Keeshond/Mix
Kelpie
Kelpie, Australian
Kelpie, Australian/Mix
Kishu
Klee Kai
Klee Kai, Alaskan
Komondor
Kooikerhondje
Koolie, Australian
Koolie, German
Kromfohrlander, Smooth Coat
Kromfohrlander, Wire Haired
Kuvasz
Kuvasz/Mix
Kyi Leo
Labradoodle
Lagotto Romagnolo
Landseer
Lapphund, Finnish
Lapphund, Finnish/Mix
Leonberger
Leonberger/Mix
Lhasa Apso
Lhasa Apso/Mix
Löwchen
Lowchen/Mix
Malamute, Alaskan
Malamute, Alaskan/Mix
Maltese
Maltese/Mix
Maltipoo
Mastiff
Mastiff, Abruzzese
Mastiff, American Bandogge
Mastiff, American Bandogge/Mix
Mastiff, Bullmastiff
Mastiff, Bullmastiff/Mix
Mastiff, Cane Corso
Mastiff, Cane Corso/Mix
Mastiff, English
Mastiff, English/Mix
Mastiff, Korean
Mastiff, Neapolitan
Mastiff, Neapolitan/Mix
Mastiff, Tibetan
Mastiff, Tibetan/Mix
Mastiff/Mix
Mixed
Mountain Dog
Mountain Dog, Appenzell
Mountain Dog, Appenzell/Mix
Mountain Dog, Bernese
Mountain Dog, Bernese/Mix
Mountain Dog, Estrela
Mountain Dog, Greater Swiss
Mountain Dog, Greater Swiss/Mix
Mountain Dog, Taiwanese
Mudi
Münsterländer
Native American Indian Dog
New Guinea Singing Dog
Newfoundland
Newfoundland/Mix
Norrbottenspets
Norwegian Buhund
Norwegian Buhund/Mix
Norwegian Lundehund
Nureongi
Otterhound
Otterhound/Mix
Papillon
Papillon/Mix
Pekingese
Pekingese/Mix
Perdigueiro Galego
Peruvian Inca Orchid
Pinscher
Pinscher, Austrian
Pinscher, Austrian/Mix
Pinscher, Doberman
Pinscher, Doberman/Mix
Pinscher, German
Pinscher, German/Mix
Pinscher, Miniature
Pinscher, Miniature/Mix
Podenco Canario
Podengo Portugueso
Pointer
Pointer, English
Pointer, German Longhaired
Pointer, German Shorthaired
Pointer, German Shorthaired/Mix
Pointer, German Wirehaired
Pointer, German Wirehaired/Mix
Pointer, Podenco Galego
Pointer/Mix
Pomeranian
Pomeranian/Mix
Poodle
Poodle, Miniature
Poodle, Miniature/Mix
Poodle, Standard
Poodle, Standard/Mix
Poodle, Toy
Poodle, Toy/Mix
Poodle/Mix
Portuguese Water Dog
Portuguese Water Dog/Mix
Pudelpointer
Pug
Pug, American Lo-Sze
Pug/Mix
Puggle
Puli
Pumi
Pungsan
Pyrenees, Great
Pyrenees, Great/Mix
Rafeiro do Alentejo
Retriever
Retriever, Black Labrador
Retriever, Black Labrador/Mix
Retriever, Chesapeake Bay
Retriever, Chesapeake Bay/Mix
Retriever, Chocolate Labrador
Retriever, Chocolate Labrador/Mix
Retriever, Curly-Coated
Retriever, Curly-Coated/Mix
Retriever, Flat-Coated
Retriever, Flat-Coated/Mix
Retriever, Golden
Retriever, Golden/Mix
Retriever, Labrador
Retriever, Labrador/Mix
Retriever, Nova Scotia Duck-Tolling
Retriever, Nova Scotia Duck-Tolling/Mix
Retriever, Yellow Labrador
Retriever, Yellow Labrador/Mix
Retriever/Mix
Ridgeback, Rhodesian
Ridgeback, Rhodesian/Mix
Ridgeback, Thai
Ridgeback, Thai/Mix
Rottweiler
Rottweiler/Mix
Saint Bernard
Saint Bernard/Mix
Saluki
Saluki/Mix
Samoyed
Samoyed/Mix
Schipperke
Schipperke/Mix
Schnauzer
Schnauzer, Giant
Schnauzer, Giant/Mix
Schnauzer, Miniature
Schnauzer, Miniature/Mix
Schnauzer, Standard
Schnauzer, Standard/Mix
Schnauzer/Mix
Setter
Setter, English
Setter, English/Mix
Setter, Gordon
Setter, Gordon/Mix
Setter, Irish
Setter, Irish Red and White
Setter, Irish/Mix
Shar Pei
Shar Pei/Mix
Sheepdog
Sheepdog, Bergamasco
Sheepdog, Caucasian Ovtcharka
Sheepdog, Croatian
Sheepdog, Dutch
Sheepdog, Icelandic
Sheepdog, Illyrian
Sheepdog, Maremma
Sheepdog, Mcnab
Sheepdog, Mcnab/Mix
Sheepdog, Old English
Sheepdog, Old English/Mix
Sheepdog, Picardy
Sheepdog, Polish Lowland
Sheepdog, Polish Lowland/Mix
Sheepdog, Portuguese
Sheepdog, Shetland
Sheepdog, Shetland/Mix
Sheepdog/Mix
Shepherd
Shepherd, Anatolian
Shepherd, Anatolian/Mix
Shepherd, Australian
Shepherd, Australian, Miniature
Shepherd, Australian/Mix
Shepherd, Belgian Groenendael
Shepherd, Belgian Laekenois
Shepherd, Belgian Malinois
Shepherd, Belgian Malinois/Mix
Shepherd, Belgian Sheepdog
Shepherd, Belgian Sheepdog/Mix
Shepherd, Belgian Tervuren
Shepherd, Belgian Tervuren/Mix
Shepherd, Carpathian
Shepherd, Central Asian
Shepherd, Dutch
Shepherd, Dutch/Mix
Shepherd, English
Shepherd, English/Mix
Shepherd, German
Shepherd, German King
Shepherd, German King/Mix
Shepherd, German/Mix
Shepherd, Miniature
Shepherd, Pyrenean
Shepherd, Shiloh
Shepherd, White German
Shepherd, White German/Mix
Shepherd, White Swiss (Berger Blanc Suisse)
Shepherd/Mix
Shiba Inu
Shiba Inu/Mix
Shih Tzu
Shih Tzu/Mix
Silken Windhound
Sloughi
South Russian Ovcharkas
Spaniel
Spaniel, American Cocker
Spaniel, American Cocker/Mix
Spaniel, American Water
Spaniel, American Water/Mix
Spaniel, Boykin
Spaniel, Brittany
Spaniel, Brittany, French
Spaniel, Brittany/Mix
Spaniel, Cavalier King Charles
Spaniel, Cavalier King Charles/Mix
Spaniel, Clumber
Spaniel, Clumber/Mix
Spaniel, Cocker
Spaniel, Cocker/Mix
Spaniel, English Cocker
Spaniel, English Cocker/Mix
Spaniel, English Springer
Spaniel, English Springer/Mix
Spaniel, English Toy
Spaniel, English Toy/Mix
Spaniel, Field
Spaniel, French
Spaniel, Irish Water
Spaniel, Springer
Spaniel, Sussex
Spaniel, Sussex/Mix
Spaniel, Swedish
Spaniel, Tibetan
Spaniel, Tibetan/Mix
Spaniel, Welsh Springer
Spaniel, Welsh Springer/Mix
Spaniel/Mix
Spanish Water Dog
Spitz
Spitz, Finnish
Spitz, Finnish/Mix
Spitz, German
Spitz, German/Mix
Spitz, Japanese
Spitz/Mix
Stabyhoun
Tahltan Bear Dog
Teddy Bear
Teddy Poo
Terrier
Terrier, Abyssinian Sand
Terrier, Airedale
Terrier, Airedale/Mix
Terrier, American Crested Sand
Terrier, American Hairless
Terrier, American Hairless/Mix
Terrier, American Pit Bull
Terrier, American Pit Bull/Mix
Terrier, American Staffordshire
Terrier, American Staffordshire/Mix
Terrier, Australian
Terrier, Australian/Mix
Terrier, Bedlington
Terrier, Bedlington/Mix
Terrier, Black Russian
Terrier, Border
Terrier, Border/Mix
Terrier, Boston
Terrier, Boston/Mix
Terrier, Brazilian
Terrier, Bull
Terrier, Bull, Miniature
Terrier, Bull, Miniature/Mix
Terrier, Bull/Mix
Terrier, Cairn
Terrier, Cairn/Mix
Terrier, Cesky
Terrier, Dandi Dinmont
Terrier, Fox
Terrier, Fox, Miniature
Terrier, Fox, Miniature/Mix
Terrier, Fox, Smooth
Terrier, Fox, Smooth/Mix
Terrier, Fox, Toy
Terrier, Fox, Toy/Mix
Terrier, Fox, Wire
Terrier, Fox/Mix
Terrier, Glen of Imaal
Terrier, Glen of Imaal/Mix
Terrier, Irish
Terrier, Irish/Mix
Terrier, Jack Russell
Terrier, Jack Russell Wirehaired
Terrier, Jack Russell/Mix
Terrier, Japanese
Terrier, Kerry Blue
Terrier, Lakeland
Terrier, Manchester
Terrier, Manchester, Toy
Terrier, Manchester/Mix
Terrier, Norfolk
Terrier, Norfolk/Mix
Terrier, Norwich
Terrier, Norwich/Mix
Terrier, Parson Russell
Terrier, Parson Russell/Mix
Terrier, Patterdale (Fell)
Terrier, Patterdale (Fell)/Mix
Terrier, Pit Bull
Terrier, Pit Bull/Mix
Terrier, Rat
Terrier, Rat/Mix
Terrier, Scottish Scottie
Terrier, Scottish Scottie/Mix
Terrier, Sealyham
Terrier, Silky
Terrier, Silky Australian
Terrier, Silky/Mix
Terrier, Skye
Terrier, Skye/Mix
Terrier, Soft Coated Wheaten
Terrier, Soft Coated Wheaten/Mix
Terrier, Staffordshire Bull
Terrier, Staffordshire Bull/Mix
Terrier, Tenterfield
Terrier, Tibetan
Terrier, Tibetan/Mix
Terrier, Welsh
Terrier, Welsh/Mix
Terrier, West Highland White Westie
Terrier, West Highland White Westie/Mix
Terrier, Wheaten
Terrier, Wire Fox
Terrier, Wire Fox/Mix
Terrier, Wirehaired
Terrier, Wirehaired/Mix
Terrier, Yorkshire, Yorkie
Terrier, Yorkshire, Yorkie/Mix
Terrier/Mix
Tosa Inu
Treeing Tennessee Brindle
Unknown
Vallhund, Swedish
Vallhund, Swedish/Mix
Vizsla
Vizsla, Hungarian
Vizsla, Smooth Haired
Vizsla, Smooth Haired/Mix
Vizsla, Wire Haired
Vizsla/Mix
Volpino Italiano
Weimaraner
Weimaraner/Mix
Whippet
Whippet/Mix
Wolf
Wolf, Hybrid
Wolf, Hybrid/Mix
Wolf/Mix
Wolfdog
Wolfdog, Czechoslovakian
Wolfdog, Czechoslovakian/Mix
Wolfdog, Saarloos
Wolfdog, Saarloos/aMix
Wolfdog/Mix
Wolfhound, Irish
Xoloitzcuintle (Mexican Hairless)
Xoloitzcuintle (Mexican Hairless)/Mix
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Cat Breed
* Domestic Long Hair *
* Domestic Medium Hair *
* Domestic Short Hair *
Abyssinian
Abyssinian/Mix
American Bobtail
American Bobtail/Mix
American Curl
American Curl/Mix
American Shorthair
American Shorthair/Mix
American Wirehair
American Wirehair/Mix
Applehead Siamese
Balinese
Balinese/Mix
Bengal
Bengal/Mix
Birman
Birman/Mix
Bobtail
Bombay
Bombay/Mix
British Longhair
British Longhair/Mix
British Shorthair
British Shorthair/Mix
Burmese
Burmese/Mix
Burmilla
Calico
Calico/Mix
California Spangled
Canadian Hairless
Chantilly
Chartreux
Chartreux/Mix
Chausie
Chinchilla
Chinese Domestic
Colorpoint Shorthair
Colorpoint Shorthair/Mix
Cornish Rex
Cornish Rex/Mix
Cymric
Cymric/Mix
Desert Lynx
Devon Rex
Devon Rex/Mix
Dilute Calico
Dilute Tortoiseshell
Domestic Longhair/Mix
Domestic Medium Hair/Mix
Domestic Shorthair/Mix
Egyptian Mau
Egyptian Mau/Mix
European Shorthair
Exotic Longhair
Exotic Longhair/Mix
Exotic Shorthair
Exotic Shorthair/Mix
Extra-Toes Cat (Hemingway Polydactyl)
Extra-Toes Cat (Hemingway Polydactyl)/Mix
Feral
Havana Brown
Havana Brown/Mix
Highlander
Himalayan
Himalayan/Mix
Japanese Bobtail
Japanese Bobtail/Mix
Javanese
Javanese/Mix
Kashmir
Khao-Manee
Korat
Laperm
Maine Coon
Maine Coon/Mix
Manx
Manx/Mix
Mixed
Munchkin
Munchkin/Mix
Nebelung
Norwegian Forest Cat
Norwegian Forest Cat/Mix
Ocicat
Ocicat/Mix
Oriental Long Hair
Oriental Long Hair/Mix
Oriental Short Hair
Oriental Tabby
Persian
Persian/Mix
Pixie-Bob
Pixie-Bob/Mix
Ragamuffin
Ragamuffin/Mix
Ragdoll
Ragdoll/Mix
Russian Blue
Russian Blue/Mix
Savannah
Scottish Fold
Scottish Fold/Mix
Selkirk Rex
Selkirk Rex/Mix
Siamese
Siamese/Mix
Siberian
Siberian/Mix
Silver
Singapura
Singapura/Mix
Snowshoe
Snowshoe/Mix
Sokoke
Somali
Sphynx
Sphynx/Mix
Tabby
Tiger
Tonkinese
Tonkinese/Mix
Torbie
Tortoiseshell
Toyger
Turkish Angora
Turkish Angora/Mix
Turkish Van
Turkish Van/Mix
Tuxedo
Unknown
York Chocolate
52
Other Pet Species
53
Medical Event
54
Has this pet had their rabies vaccination?
Yes (Rabies)
No (Rabies)
55
Vaccine Name
56
Date of Vaccination
Please use XX/XX/XXXX format.
57
Where did they receive this vaccine?
58
What vet office does your pet use?
Put N/A if they do not have one.
59
Please list your pet's current medications, illnesses, injuries, or ailments.
60
Has your pet ever bitten anyone?* This field is required.
Yes
No
61
Please give us a brief description of the bite incident.
62
Add a photo of your pet
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
63
Do you have a second pet?* This field is required.
Yes
No
64
Second Pet's Name
65
Type
Dog
Cat
Other
66
Age
67
Weight
68
Gender
Female
Female Spayed
Male
Male Neutered
Unknown
69
Dog Breed
* Mixed Breed Large (>45 Lbs Fully Grown) *
* Mixed Breed Med (25-44 Lbs Fully Grown) *
* Mixed Breed Small (<25 Lbs Fully Grown) *
Affenpinscher
Affenpinscher/Mix
Aidi
Ainu
Akbash
Akbash/Mix
Akita
Akita Inu
Akita/Mix
Alano Español
Alopekis
Alpine Dachsbracke
American Bully
American Bully/Mix
Appenzeller Sennenhunde
Armant
Azawakh
Bahamian Potcake
Barbet
Basenji
Basenji/Mix
Beagle
Beagle, Kerry
Beagle/Mix
Beauceron
Beauceron/Mix
Berger Picard
Bichon Frise
Bichon Frise/Mix
Blue Heeler
Blue Heeler, American
Blue Heeler, American/Mix
Blue Lacy
Blue Lacy/Mix
Boerboel
Boerboel/Mix
Bolognese
Bolognese/Mix
Bolonka
Borzoi
Borzoi/Mix
Bouvier des Ardennes
Bouvier Des Flandres
Bouvier Des Flandres/Mix
Boxer
Boxer/Mix
Bracco Italiano
Braque Francais, Gascogne
Braque Francais, Pyrenees
Brasileiro, Fila
Brasileiro, Fila/Mix
Briard
Briard/Mix
Bull Arab
Bull Arab/Mix
Bulldog
Bulldog, Alapaha Blue Blood
Bulldog, Alapaha Blue Blood/Mix
Bulldog, American
Bulldog, American/Mix
Bulldog, Australian
Bulldog, Australian/Mix
Bulldog, British
Bulldog, British/Mix
Bulldog, English
Bulldog, English/Mix
Bulldog, French
Bulldog, French/Mix
Bulldog, Johnson
Bulldog, Johnson/Mix
Bulldog, Old English
Bulldog, Old English/Mix
Bulldog, Victorian
Bulldog, Victorian/Mix
Bulldog/Mix
Bulldogge, Banter
Bulldogge, Banter/Mix
Cambodian Razorback Dog
Canaan Dog
Canaan Dog/Mix
Canario, Presa
Canario, Presa/Mix
Cane Di Oropa
Cane Toccatore
Carolina Dog
Carolina Dog/Mix
Castro Laboreiro Dog
Catahoula Leopard Dog
Catahoula Leopard Dog/Mix
Cattle Dog
Cattle Dog, Australian
Cattle Dog, Australian (Blue Heeler)
Cattle Dog, Australian (Blue Heeler)/Mix
Cattle Dog, Australian (Red Heeler)
Cattle Dog, Australian (Red Heeler)/Mix
Cattle Dog, Azores
Cattle Dog, Smithfield
Cattle Dog/Mix
Chihuahua
Chihuahua, Long Coat
Chihuahua, Long Coat/Mix
Chihuahua, Short Coat
Chihuahua, Short Coat/Mix
Chihuahua/Mix
Chinese Crested Dog
Chinese Crested Dog/Mix
Chinese Foo Dog
Chinese Shar-Pei
Chinese Shar-Pei/Mix
Chinook
Chow Chow
Chow Chow/Mix
Cimarrón Uruguayo
Cirneco Dell'etna
Cockapoo
Cockapoo/Mix
Collie
Collie, Bearded
Collie, Bearded/Mix
Collie, Border
Collie, Border/Mix
Collie, Rough
Collie, Rough/Mix
Collie, Smooth
Collie, Smooth/Mix
Collie/Mix
Coonhound
Coonhound, American English
Coonhound, Black and Tan
Coonhound, Black and Tan/Mix
Coonhound, Bluetick
Coonhound, Bluetick/Mix
Coonhound, English
Coonhound, English/Mix
Coonhound, Redbone
Coonhound, Redbone/Mix
Coonhound, Redtick
Coonhound, Treeing Walker
Coonhound, Treeing Walker/Mix
Coonhound/Mix
Corgi
Corgi, Cardigan Welsh
Corgi, Cardigan Welsh/Mix
Corgi, Pembroke Welsh
Corgi, Pembroke Welsh/Mix
Corgi, Welsh
Corgi/Mix
Coton De Tulear
Coton De Tulear/Mix
Coyote
Coyote, Hybrid
Coyote, Hybrid/Mix
Coyote/Mix
Cur, Black Mouth
Cur, Black Mouth/Mix
Cur, Mountain
Cur, Mountain/Mix
Dachshund
Dachshund, Miniature Long Haired
Dachshund, Miniature Long Haired/Mix
Dachshund, Miniature Smooth Haired
Dachshund, Miniature Smooth Haired/Mix
Dachshund, Miniature Wire Haired
Dachshund, Miniature Wire Haired/Mix
Dachshund, Standard Long Haired
Dachshund, Standard Long Haired/Mix
Dachshund, Standard Smooth Haired
Dachshund, Standard Smooth Haired/Mix
Dachshund, Standard Wire Haired
Dachshund, Standard Wire Haired/Mix
Dachshund/Mix
Dalmatian
Dalmatian/Mix
Damchi
Danish Broholmer
Dingo
Dingo/Mix
Dogo Argentino
Dogo Argentino/Mix
Dogue De Bordeaux
Dogue de Bordeaux/Mix
Doodle/Mix
Dosa Inu
Double Doodle
Drever
Dutch Smoushond
Elkhound, Norwegian
Elkhound, Norwegian/Mix
Elkhound, Swedish
Entlebucher
Eskimo Dog
Eskimo Dog/Mix
Eskimo, American
Eskimo, American/Mix
Eskimo, Canadian
Eurasier
Feist
Feist/Mix
Fox, Hybrid
Fox, Hybrid/Mix
Fox/Mix
Foxhound
Foxhound, American
Foxhound, American/Mix
Foxhound, English
Foxhound, English/Mix
Goldendoodle
Great Dane
Great Dane/Mix
Greenland Dog
Greyhound
Greyhound, Galgo Pinscher
Greyhound, Italian
Greyhound, Italian/Mix
Greyhound/Mix
Griffon Vendeen, Briquet
Griffon Vendeen, Grand Basset
Griffon Vendeen, Petit Basset
Griffon, Belgian
Griffon, Brussels
Griffon, Brussels/Mix
Griffon, Wire-Haired Pointing
Griffon, Wire-Haired Pointing/Mix
Harrier
Havanese
Havanese/Mix
Heeler, Lancashire
Heeler, Queensland
Heeler, Queensland/Mix
Hound
Hound, Afghan
Hound, Afghan/Mix
Hound, American Blue Gascon
Hound, Basset
Hound, Basset/Mix
Hound, Bloodhound
Hound, Bloodhound/Mix
Hound, Dunker
Hound, Halden (Haldenstover)
Hound, Hygen
Hound, Ibizan
Hound, Ibizan/Mix
Hound, Irish Wolfhound
Hound, Irish Wolfhound/Mix
Hound, Pharaoh
Hound, Pharaoh/Mix
Hound, Plott
Hound, Plott/Mix
Hound, Schweizer Laufhund
Hound, Scottish Deerhound
Hound, Staghound
Hound/Mix
Hovawart
Husky
Husky, Alaskan
Husky, Alaskan/Mix
Husky, Siberian
Husky, Siberian/Mix
Husky/Mix
Italian Spinone
Japanese Chin
Japanese Chin/Mix
Jindo
Jindo, Korean
Jindo, Korean/Mix
Kai Dog
Kai Dog/Mix
Karakachan
Karelian Bear Dog
Karelian Bear Dog/Mix
Keeshond
Keeshond/Mix
Kelpie
Kelpie, Australian
Kelpie, Australian/Mix
Kishu
Klee Kai
Klee Kai, Alaskan
Komondor
Kooikerhondje
Koolie, Australian
Koolie, German
Kromfohrlander, Smooth Coat
Kromfohrlander, Wire Haired
Kuvasz
Kuvasz/Mix
Kyi Leo
Labradoodle
Lagotto Romagnolo
Landseer
Lapphund, Finnish
Lapphund, Finnish/Mix
Leonberger
Leonberger/Mix
Lhasa Apso
Lhasa Apso/Mix
Löwchen
Lowchen/Mix
Malamute, Alaskan
Malamute, Alaskan/Mix
Maltese
Maltese/Mix
Maltipoo
Mastiff
Mastiff, Abruzzese
Mastiff, American Bandogge
Mastiff, American Bandogge/Mix
Mastiff, Bullmastiff
Mastiff, Bullmastiff/Mix
Mastiff, Cane Corso
Mastiff, Cane Corso/Mix
Mastiff, English
Mastiff, English/Mix
Mastiff, Korean
Mastiff, Neapolitan
Mastiff, Neapolitan/Mix
Mastiff, Tibetan
Mastiff, Tibetan/Mix
Mastiff/Mix
Mixed
Mountain Dog
Mountain Dog, Appenzell
Mountain Dog, Appenzell/Mix
Mountain Dog, Bernese
Mountain Dog, Bernese/Mix
Mountain Dog, Estrela
Mountain Dog, Greater Swiss
Mountain Dog, Greater Swiss/Mix
Mountain Dog, Taiwanese
Mudi
Münsterländer
Native American Indian Dog
New Guinea Singing Dog
Newfoundland
Newfoundland/Mix
Norrbottenspets
Norwegian Buhund
Norwegian Buhund/Mix
Norwegian Lundehund
Nureongi
Otterhound
Otterhound/Mix
Papillon
Papillon/Mix
Pekingese
Pekingese/Mix
Perdigueiro Galego
Peruvian Inca Orchid
Pinscher
Pinscher, Austrian
Pinscher, Austrian/Mix
Pinscher, Doberman
Pinscher, Doberman/Mix
Pinscher, German
Pinscher, German/Mix
Pinscher, Miniature
Pinscher, Miniature/Mix
Podenco Canario
Podengo Portugueso
Pointer
Pointer, English
Pointer, German Longhaired
Pointer, German Shorthaired
Pointer, German Shorthaired/Mix
Pointer, German Wirehaired
Pointer, German Wirehaired/Mix
Pointer, Podenco Galego
Pointer/Mix
Pomeranian
Pomeranian/Mix
Poodle
Poodle, Miniature
Poodle, Miniature/Mix
Poodle, Standard
Poodle, Standard/Mix
Poodle, Toy
Poodle, Toy/Mix
Poodle/Mix
Portuguese Water Dog
Portuguese Water Dog/Mix
Pudelpointer
Pug
Pug, American Lo-Sze
Pug/Mix
Puggle
Puli
Pumi
Pungsan
Pyrenees, Great
Pyrenees, Great/Mix
Rafeiro do Alentejo
Retriever
Retriever, Black Labrador
Retriever, Black Labrador/Mix
Retriever, Chesapeake Bay
Retriever, Chesapeake Bay/Mix
Retriever, Chocolate Labrador
Retriever, Chocolate Labrador/Mix
Retriever, Curly-Coated
Retriever, Curly-Coated/Mix
Retriever, Flat-Coated
Retriever, Flat-Coated/Mix
Retriever, Golden
Retriever, Golden/Mix
Retriever, Labrador
Retriever, Labrador/Mix
Retriever, Nova Scotia Duck-Tolling
Retriever, Nova Scotia Duck-Tolling/Mix
Retriever, Yellow Labrador
Retriever, Yellow Labrador/Mix
Retriever/Mix
Ridgeback, Rhodesian
Ridgeback, Rhodesian/Mix
Ridgeback, Thai
Ridgeback, Thai/Mix
Rottweiler
Rottweiler/Mix
Saint Bernard
Saint Bernard/Mix
Saluki
Saluki/Mix
Samoyed
Samoyed/Mix
Schipperke
Schipperke/Mix
Schnauzer
Schnauzer, Giant
Schnauzer, Giant/Mix
Schnauzer, Miniature
Schnauzer, Miniature/Mix
Schnauzer, Standard
Schnauzer, Standard/Mix
Schnauzer/Mix
Setter
Setter, English
Setter, English/Mix
Setter, Gordon
Setter, Gordon/Mix
Setter, Irish
Setter, Irish Red and White
Setter, Irish/Mix
Shar Pei
Shar Pei/Mix
Sheepdog
Sheepdog, Bergamasco
Sheepdog, Caucasian Ovtcharka
Sheepdog, Croatian
Sheepdog, Dutch
Sheepdog, Icelandic
Sheepdog, Illyrian
Sheepdog, Maremma
Sheepdog, Mcnab
Sheepdog, Mcnab/Mix
Sheepdog, Old English
Sheepdog, Old English/Mix
Sheepdog, Picardy
Sheepdog, Polish Lowland
Sheepdog, Polish Lowland/Mix
Sheepdog, Portuguese
Sheepdog, Shetland
Sheepdog, Shetland/Mix
Sheepdog/Mix
Shepherd
Shepherd, Anatolian
Shepherd, Anatolian/Mix
Shepherd, Australian
Shepherd, Australian, Miniature
Shepherd, Australian/Mix
Shepherd, Belgian Groenendael
Shepherd, Belgian Laekenois
Shepherd, Belgian Malinois
Shepherd, Belgian Malinois/Mix
Shepherd, Belgian Sheepdog
Shepherd, Belgian Sheepdog/Mix
Shepherd, Belgian Tervuren
Shepherd, Belgian Tervuren/Mix
Shepherd, Carpathian
Shepherd, Central Asian
Shepherd, Dutch
Shepherd, Dutch/Mix
Shepherd, English
Shepherd, English/Mix
Shepherd, German
Shepherd, German King
Shepherd, German King/Mix
Shepherd, German/Mix
Shepherd, Miniature
Shepherd, Pyrenean
Shepherd, Shiloh
Shepherd, White German
Shepherd, White German/Mix
Shepherd, White Swiss (Berger Blanc Suisse)
Shepherd/Mix
Shiba Inu
Shiba Inu/Mix
Shih Tzu
Shih Tzu/Mix
Silken Windhound
Sloughi
South Russian Ovcharkas
Spaniel
Spaniel, American Cocker
Spaniel, American Cocker/Mix
Spaniel, American Water
Spaniel, American Water/Mix
Spaniel, Boykin
Spaniel, Brittany
Spaniel, Brittany, French
Spaniel, Brittany/Mix
Spaniel, Cavalier King Charles
Spaniel, Cavalier King Charles/Mix
Spaniel, Clumber
Spaniel, Clumber/Mix
Spaniel, Cocker
Spaniel, Cocker/Mix
Spaniel, English Cocker
Spaniel, English Cocker/Mix
Spaniel, English Springer
Spaniel, English Springer/Mix
Spaniel, English Toy
Spaniel, English Toy/Mix
Spaniel, Field
Spaniel, French
Spaniel, Irish Water
Spaniel, Springer
Spaniel, Sussex
Spaniel, Sussex/Mix
Spaniel, Swedish
Spaniel, Tibetan
Spaniel, Tibetan/Mix
Spaniel, Welsh Springer
Spaniel, Welsh Springer/Mix
Spaniel/Mix
Spanish Water Dog
Spitz
Spitz, Finnish
Spitz, Finnish/Mix
Spitz, German
Spitz, German/Mix
Spitz, Japanese
Spitz/Mix
Stabyhoun
Tahltan Bear Dog
Teddy Bear
Teddy Poo
Terrier
Terrier, Abyssinian Sand
Terrier, Airedale
Terrier, Airedale/Mix
Terrier, American Crested Sand
Terrier, American Hairless
Terrier, American Hairless/Mix
Terrier, American Pit Bull
Terrier, American Pit Bull/Mix
Terrier, American Staffordshire
Terrier, American Staffordshire/Mix
Terrier, Australian
Terrier, Australian/Mix
Terrier, Bedlington
Terrier, Bedlington/Mix
Terrier, Black Russian
Terrier, Border
Terrier, Border/Mix
Terrier, Boston
Terrier, Boston/Mix
Terrier, Brazilian
Terrier, Bull
Terrier, Bull, Miniature
Terrier, Bull, Miniature/Mix
Terrier, Bull/Mix
Terrier, Cairn
Terrier, Cairn/Mix
Terrier, Cesky
Terrier, Dandi Dinmont
Terrier, Fox
Terrier, Fox, Miniature
Terrier, Fox, Miniature/Mix
Terrier, Fox, Smooth
Terrier, Fox, Smooth/Mix
Terrier, Fox, Toy
Terrier, Fox, Toy/Mix
Terrier, Fox, Wire
Terrier, Fox/Mix
Terrier, Glen of Imaal
Terrier, Glen of Imaal/Mix
Terrier, Irish
Terrier, Irish/Mix
Terrier, Jack Russell
Terrier, Jack Russell Wirehaired
Terrier, Jack Russell/Mix
Terrier, Japanese
Terrier, Kerry Blue
Terrier, Lakeland
Terrier, Manchester
Terrier, Manchester, Toy
Terrier, Manchester/Mix
Terrier, Norfolk
Terrier, Norfolk/Mix
Terrier, Norwich
Terrier, Norwich/Mix
Terrier, Parson Russell
Terrier, Parson Russell/Mix
Terrier, Patterdale (Fell)
Terrier, Patterdale (Fell)/Mix
Terrier, Pit Bull
Terrier, Pit Bull/Mix
Terrier, Rat
Terrier, Rat/Mix
Terrier, Scottish Scottie
Terrier, Scottish Scottie/Mix
Terrier, Sealyham
Terrier, Silky
Terrier, Silky Australian
Terrier, Silky/Mix
Terrier, Skye
Terrier, Skye/Mix
Terrier, Soft Coated Wheaten
Terrier, Soft Coated Wheaten/Mix
Terrier, Staffordshire Bull
Terrier, Staffordshire Bull/Mix
Terrier, Tenterfield
Terrier, Tibetan
Terrier, Tibetan/Mix
Terrier, Welsh
Terrier, Welsh/Mix
Terrier, West Highland White Westie
Terrier, West Highland White Westie/Mix
Terrier, Wheaten
Terrier, Wire Fox
Terrier, Wire Fox/Mix
Terrier, Wirehaired
Terrier, Wirehaired/Mix
Terrier, Yorkshire, Yorkie
Terrier, Yorkshire, Yorkie/Mix
Terrier/Mix
Tosa Inu
Treeing Tennessee Brindle
Unknown
Vallhund, Swedish
Vallhund, Swedish/Mix
Vizsla
Vizsla, Hungarian
Vizsla, Smooth Haired
Vizsla, Smooth Haired/Mix
Vizsla, Wire Haired
Vizsla/Mix
Volpino Italiano
Weimaraner
Weimaraner/Mix
Whippet
Whippet/Mix
Wolf
Wolf, Hybrid
Wolf, Hybrid/Mix
Wolf/Mix
Wolfdog
Wolfdog, Czechoslovakian
Wolfdog, Czechoslovakian/Mix
Wolfdog, Saarloos
Wolfdog, Saarloos/aMix
Wolfdog/Mix
Wolfhound, Irish
Xoloitzcuintle (Mexican Hairless)
Xoloitzcuintle (Mexican Hairless)/Mix
70
Cat Breed
* Domestic Long Hair *
* Domestic Medium Hair *
* Domestic Short Hair *
Abyssinian
Abyssinian/Mix
American Bobtail
American Bobtail/Mix
American Curl
American Curl/Mix
American Shorthair
American Shorthair/Mix
American Wirehair
American Wirehair/Mix
Applehead Siamese
Balinese
Balinese/Mix
Bengal
Bengal/Mix
Birman
Birman/Mix
Bobtail
Bombay
Bombay/Mix
British Longhair
British Longhair/Mix
British Shorthair
British Shorthair/Mix
Burmese
Burmese/Mix
Burmilla
Calico
Calico/Mix
California Spangled
Canadian Hairless
Chantilly
Chartreux
Chartreux/Mix
Chausie
Chinchilla
Chinese Domestic
Colorpoint Shorthair
Colorpoint Shorthair/Mix
Cornish Rex
Cornish Rex/Mix
Cymric
Cymric/Mix
Desert Lynx
Devon Rex
Devon Rex/Mix
Dilute Calico
Dilute Tortoiseshell
Domestic Longhair/Mix
Domestic Medium Hair/Mix
Domestic Shorthair/Mix
Egyptian Mau
Egyptian Mau/Mix
European Shorthair
Exotic Longhair
Exotic Longhair/Mix
Exotic Shorthair
Exotic Shorthair/Mix
Extra-Toes Cat (Hemingway Polydactyl)
Extra-Toes Cat (Hemingway Polydactyl)/Mix
Feral
Havana Brown
Havana Brown/Mix
Highlander
Himalayan
Himalayan/Mix
Japanese Bobtail
Japanese Bobtail/Mix
Javanese
Javanese/Mix
Kashmir
Khao-Manee
Korat
Laperm
Maine Coon
Maine Coon/Mix
Manx
Manx/Mix
Mixed
Munchkin
Munchkin/Mix
Nebelung
Norwegian Forest Cat
Norwegian Forest Cat/Mix
Ocicat
Ocicat/Mix
Oriental Long Hair
Oriental Long Hair/Mix
Oriental Short Hair
Oriental Tabby
Persian
Persian/Mix
Pixie-Bob
Pixie-Bob/Mix
Ragamuffin
Ragamuffin/Mix
Ragdoll
Ragdoll/Mix
Russian Blue
Russian Blue/Mix
Savannah
Scottish Fold
Scottish Fold/Mix
Selkirk Rex
Selkirk Rex/Mix
Siamese
Siamese/Mix
Siberian
Siberian/Mix
Silver
Singapura
Singapura/Mix
Snowshoe
Snowshoe/Mix
Sokoke
Somali
Sphynx
Sphynx/Mix
Tabby
Tiger
Tonkinese
Tonkinese/Mix
Torbie
Tortoiseshell
Toyger
Turkish Angora
Turkish Angora/Mix
Turkish Van
Turkish Van/Mix
Tuxedo
Unknown
York Chocolate
71
Other Species
72
Medical Event
73
Has this pet had their rabies vaccination?
Yes (Rabies)
No (Rabies)
74
Vaccine Name
75
Date of Vaccination
Please use XX/XX/XXXX format.
76
Where did they receive this vaccine?
77
What vet office does your pet use?
Put N/A if they do not have one.
78
Please list your pet's current medications, illnesses, injuries, or ailments.
79
Has your pet ever bitten anyone?* This field is required.
Yes
No
80
Please give us a brief description of the bite incident.
81
Add a photo of your pet
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
82
Do you have a third pet?* This field is required.
Yes
No
83
Third Pet's Name
84
Type
Dog
Cat
Other
85
Age
86
Weight
87
Gender
Female
Female Spayed
Male
Male Neutered
Unknown
88
Dog Breed
* Mixed Breed Large (>45 Lbs Fully Grown) *
* Mixed Breed Med (25-44 Lbs Fully Grown) *
* Mixed Breed Small (<25 Lbs Fully Grown) *
Affenpinscher
Affenpinscher/Mix
Aidi
Ainu
Akbash
Akbash/Mix
Akita
Akita Inu
Akita/Mix
Alano Español
Alopekis
Alpine Dachsbracke
American Bully
American Bully/Mix
Appenzeller Sennenhunde
Armant
Azawakh
Bahamian Potcake
Barbet
Basenji
Basenji/Mix
Beagle
Beagle, Kerry
Beagle/Mix
Beauceron
Beauceron/Mix
Berger Picard
Bichon Frise
Bichon Frise/Mix
Blue Heeler
Blue Heeler, American
Blue Heeler, American/Mix
Blue Lacy
Blue Lacy/Mix
Boerboel
Boerboel/Mix
Bolognese
Bolognese/Mix
Bolonka
Borzoi
Borzoi/Mix
Bouvier des Ardennes
Bouvier Des Flandres
Bouvier Des Flandres/Mix
Boxer
Boxer/Mix
Bracco Italiano
Braque Francais, Gascogne
Braque Francais, Pyrenees
Brasileiro, Fila
Brasileiro, Fila/Mix
Briard
Briard/Mix
Bull Arab
Bull Arab/Mix
Bulldog
Bulldog, Alapaha Blue Blood
Bulldog, Alapaha Blue Blood/Mix
Bulldog, American
Bulldog, American/Mix
Bulldog, Australian
Bulldog, Australian/Mix
Bulldog, British
Bulldog, British/Mix
Bulldog, English
Bulldog, English/Mix
Bulldog, French
Bulldog, French/Mix
Bulldog, Johnson
Bulldog, Johnson/Mix
Bulldog, Old English
Bulldog, Old English/Mix
Bulldog, Victorian
Bulldog, Victorian/Mix
Bulldog/Mix
Bulldogge, Banter
Bulldogge, Banter/Mix
Cambodian Razorback Dog
Canaan Dog
Canaan Dog/Mix
Canario, Presa
Canario, Presa/Mix
Cane Di Oropa
Cane Toccatore
Carolina Dog
Carolina Dog/Mix
Castro Laboreiro Dog
Catahoula Leopard Dog
Catahoula Leopard Dog/Mix
Cattle Dog
Cattle Dog, Australian
Cattle Dog, Australian (Blue Heeler)
Cattle Dog, Australian (Blue Heeler)/Mix
Cattle Dog, Australian (Red Heeler)
Cattle Dog, Australian (Red Heeler)/Mix
Cattle Dog, Azores
Cattle Dog, Smithfield
Cattle Dog/Mix
Chihuahua
Chihuahua, Long Coat
Chihuahua, Long Coat/Mix
Chihuahua, Short Coat
Chihuahua, Short Coat/Mix
Chihuahua/Mix
Chinese Crested Dog
Chinese Crested Dog/Mix
Chinese Foo Dog
Chinese Shar-Pei
Chinese Shar-Pei/Mix
Chinook
Chow Chow
Chow Chow/Mix
Cimarrón Uruguayo
Cirneco Dell'etna
Cockapoo
Cockapoo/Mix
Collie
Collie, Bearded
Collie, Bearded/Mix
Collie, Border
Collie, Border/Mix
Collie, Rough
Collie, Rough/Mix
Collie, Smooth
Collie, Smooth/Mix
Collie/Mix
Coonhound
Coonhound, American English
Coonhound, Black and Tan
Coonhound, Black and Tan/Mix
Coonhound, Bluetick
Coonhound, Bluetick/Mix
Coonhound, English
Coonhound, English/Mix
Coonhound, Redbone
Coonhound, Redbone/Mix
Coonhound, Redtick
Coonhound, Treeing Walker
Coonhound, Treeing Walker/Mix
Coonhound/Mix
Corgi
Corgi, Cardigan Welsh
Corgi, Cardigan Welsh/Mix
Corgi, Pembroke Welsh
Corgi, Pembroke Welsh/Mix
Corgi, Welsh
Corgi/Mix
Coton De Tulear
Coton De Tulear/Mix
Coyote
Coyote, Hybrid
Coyote, Hybrid/Mix
Coyote/Mix
Cur, Black Mouth
Cur, Black Mouth/Mix
Cur, Mountain
Cur, Mountain/Mix
Dachshund
Dachshund, Miniature Long Haired
Dachshund, Miniature Long Haired/Mix
Dachshund, Miniature Smooth Haired
Dachshund, Miniature Smooth Haired/Mix
Dachshund, Miniature Wire Haired
Dachshund, Miniature Wire Haired/Mix
Dachshund, Standard Long Haired
Dachshund, Standard Long Haired/Mix
Dachshund, Standard Smooth Haired
Dachshund, Standard Smooth Haired/Mix
Dachshund, Standard Wire Haired
Dachshund, Standard Wire Haired/Mix
Dachshund/Mix
Dalmatian
Dalmatian/Mix
Damchi
Danish Broholmer
Dingo
Dingo/Mix
Dogo Argentino
Dogo Argentino/Mix
Dogue De Bordeaux
Dogue de Bordeaux/Mix
Doodle/Mix
Dosa Inu
Double Doodle
Drever
Dutch Smoushond
Elkhound, Norwegian
Elkhound, Norwegian/Mix
Elkhound, Swedish
Entlebucher
Eskimo Dog
Eskimo Dog/Mix
Eskimo, American
Eskimo, American/Mix
Eskimo, Canadian
Eurasier
Feist
Feist/Mix
Fox, Hybrid
Fox, Hybrid/Mix
Fox/Mix
Foxhound
Foxhound, American
Foxhound, American/Mix
Foxhound, English
Foxhound, English/Mix
Goldendoodle
Great Dane
Great Dane/Mix
Greenland Dog
Greyhound
Greyhound, Galgo Pinscher
Greyhound, Italian
Greyhound, Italian/Mix
Greyhound/Mix
Griffon Vendeen, Briquet
Griffon Vendeen, Grand Basset
Griffon Vendeen, Petit Basset
Griffon, Belgian
Griffon, Brussels
Griffon, Brussels/Mix
Griffon, Wire-Haired Pointing
Griffon, Wire-Haired Pointing/Mix
Harrier
Havanese
Havanese/Mix
Heeler, Lancashire
Heeler, Queensland
Heeler, Queensland/Mix
Hound
Hound, Afghan
Hound, Afghan/Mix
Hound, American Blue Gascon
Hound, Basset
Hound, Basset/Mix
Hound, Bloodhound
Hound, Bloodhound/Mix
Hound, Dunker
Hound, Halden (Haldenstover)
Hound, Hygen
Hound, Ibizan
Hound, Ibizan/Mix
Hound, Irish Wolfhound
Hound, Irish Wolfhound/Mix
Hound, Pharaoh
Hound, Pharaoh/Mix
Hound, Plott
Hound, Plott/Mix
Hound, Schweizer Laufhund
Hound, Scottish Deerhound
Hound, Staghound
Hound/Mix
Hovawart
Husky
Husky, Alaskan
Husky, Alaskan/Mix
Husky, Siberian
Husky, Siberian/Mix
Husky/Mix
Italian Spinone
Japanese Chin
Japanese Chin/Mix
Jindo
Jindo, Korean
Jindo, Korean/Mix
Kai Dog
Kai Dog/Mix
Karakachan
Karelian Bear Dog
Karelian Bear Dog/Mix
Keeshond
Keeshond/Mix
Kelpie
Kelpie, Australian
Kelpie, Australian/Mix
Kishu
Klee Kai
Klee Kai, Alaskan
Komondor
Kooikerhondje
Koolie, Australian
Koolie, German
Kromfohrlander, Smooth Coat
Kromfohrlander, Wire Haired
Kuvasz
Kuvasz/Mix
Kyi Leo
Labradoodle
Lagotto Romagnolo
Landseer
Lapphund, Finnish
Lapphund, Finnish/Mix
Leonberger
Leonberger/Mix
Lhasa Apso
Lhasa Apso/Mix
Löwchen
Lowchen/Mix
Malamute, Alaskan
Malamute, Alaskan/Mix
Maltese
Maltese/Mix
Maltipoo
Mastiff
Mastiff, Abruzzese
Mastiff, American Bandogge
Mastiff, American Bandogge/Mix
Mastiff, Bullmastiff
Mastiff, Bullmastiff/Mix
Mastiff, Cane Corso
Mastiff, Cane Corso/Mix
Mastiff, English
Mastiff, English/Mix
Mastiff, Korean
Mastiff, Neapolitan
Mastiff, Neapolitan/Mix
Mastiff, Tibetan
Mastiff, Tibetan/Mix
Mastiff/Mix
Mixed
Mountain Dog
Mountain Dog, Appenzell
Mountain Dog, Appenzell/Mix
Mountain Dog, Bernese
Mountain Dog, Bernese/Mix
Mountain Dog, Estrela
Mountain Dog, Greater Swiss
Mountain Dog, Greater Swiss/Mix
Mountain Dog, Taiwanese
Mudi
Münsterländer
Native American Indian Dog
New Guinea Singing Dog
Newfoundland
Newfoundland/Mix
Norrbottenspets
Norwegian Buhund
Norwegian Buhund/Mix
Norwegian Lundehund
Nureongi
Otterhound
Otterhound/Mix
Papillon
Papillon/Mix
Pekingese
Pekingese/Mix
Perdigueiro Galego
Peruvian Inca Orchid
Pinscher
Pinscher, Austrian
Pinscher, Austrian/Mix
Pinscher, Doberman
Pinscher, Doberman/Mix
Pinscher, German
Pinscher, German/Mix
Pinscher, Miniature
Pinscher, Miniature/Mix
Podenco Canario
Podengo Portugueso
Pointer
Pointer, English
Pointer, German Longhaired
Pointer, German Shorthaired
Pointer, German Shorthaired/Mix
Pointer, German Wirehaired
Pointer, German Wirehaired/Mix
Pointer, Podenco Galego
Pointer/Mix
Pomeranian
Pomeranian/Mix
Poodle
Poodle, Miniature
Poodle, Miniature/Mix
Poodle, Standard
Poodle, Standard/Mix
Poodle, Toy
Poodle, Toy/Mix
Poodle/Mix
Portuguese Water Dog
Portuguese Water Dog/Mix
Pudelpointer
Pug
Pug, American Lo-Sze
Pug/Mix
Puggle
Puli
Pumi
Pungsan
Pyrenees, Great
Pyrenees, Great/Mix
Rafeiro do Alentejo
Retriever
Retriever, Black Labrador
Retriever, Black Labrador/Mix
Retriever, Chesapeake Bay
Retriever, Chesapeake Bay/Mix
Retriever, Chocolate Labrador
Retriever, Chocolate Labrador/Mix
Retriever, Curly-Coated
Retriever, Curly-Coated/Mix
Retriever, Flat-Coated
Retriever, Flat-Coated/Mix
Retriever, Golden
Retriever, Golden/Mix
Retriever, Labrador
Retriever, Labrador/Mix
Retriever, Nova Scotia Duck-Tolling
Retriever, Nova Scotia Duck-Tolling/Mix
Retriever, Yellow Labrador
Retriever, Yellow Labrador/Mix
Retriever/Mix
Ridgeback, Rhodesian
Ridgeback, Rhodesian/Mix
Ridgeback, Thai
Ridgeback, Thai/Mix
Rottweiler
Rottweiler/Mix
Saint Bernard
Saint Bernard/Mix
Saluki
Saluki/Mix
Samoyed
Samoyed/Mix
Schipperke
Schipperke/Mix
Schnauzer
Schnauzer, Giant
Schnauzer, Giant/Mix
Schnauzer, Miniature
Schnauzer, Miniature/Mix
Schnauzer, Standard
Schnauzer, Standard/Mix
Schnauzer/Mix
Setter
Setter, English
Setter, English/Mix
Setter, Gordon
Setter, Gordon/Mix
Setter, Irish
Setter, Irish Red and White
Setter, Irish/Mix
Shar Pei
Shar Pei/Mix
Sheepdog
Sheepdog, Bergamasco
Sheepdog, Caucasian Ovtcharka
Sheepdog, Croatian
Sheepdog, Dutch
Sheepdog, Icelandic
Sheepdog, Illyrian
Sheepdog, Maremma
Sheepdog, Mcnab
Sheepdog, Mcnab/Mix
Sheepdog, Old English
Sheepdog, Old English/Mix
Sheepdog, Picardy
Sheepdog, Polish Lowland
Sheepdog, Polish Lowland/Mix
Sheepdog, Portuguese
Sheepdog, Shetland
Sheepdog, Shetland/Mix
Sheepdog/Mix
Shepherd
Shepherd, Anatolian
Shepherd, Anatolian/Mix
Shepherd, Australian
Shepherd, Australian, Miniature
Shepherd, Australian/Mix
Shepherd, Belgian Groenendael
Shepherd, Belgian Laekenois
Shepherd, Belgian Malinois
Shepherd, Belgian Malinois/Mix
Shepherd, Belgian Sheepdog
Shepherd, Belgian Sheepdog/Mix
Shepherd, Belgian Tervuren
Shepherd, Belgian Tervuren/Mix
Shepherd, Carpathian
Shepherd, Central Asian
Shepherd, Dutch
Shepherd, Dutch/Mix
Shepherd, English
Shepherd, English/Mix
Shepherd, German
Shepherd, German King
Shepherd, German King/Mix
Shepherd, German/Mix
Shepherd, Miniature
Shepherd, Pyrenean
Shepherd, Shiloh
Shepherd, White German
Shepherd, White German/Mix
Shepherd, White Swiss (Berger Blanc Suisse)
Shepherd/Mix
Shiba Inu
Shiba Inu/Mix
Shih Tzu
Shih Tzu/Mix
Silken Windhound
Sloughi
South Russian Ovcharkas
Spaniel
Spaniel, American Cocker
Spaniel, American Cocker/Mix
Spaniel, American Water
Spaniel, American Water/Mix
Spaniel, Boykin
Spaniel, Brittany
Spaniel, Brittany, French
Spaniel, Brittany/Mix
Spaniel, Cavalier King Charles
Spaniel, Cavalier King Charles/Mix
Spaniel, Clumber
Spaniel, Clumber/Mix
Spaniel, Cocker
Spaniel, Cocker/Mix
Spaniel, English Cocker
Spaniel, English Cocker/Mix
Spaniel, English Springer
Spaniel, English Springer/Mix
Spaniel, English Toy
Spaniel, English Toy/Mix
Spaniel, Field
Spaniel, French
Spaniel, Irish Water
Spaniel, Springer
Spaniel, Sussex
Spaniel, Sussex/Mix
Spaniel, Swedish
Spaniel, Tibetan
Spaniel, Tibetan/Mix
Spaniel, Welsh Springer
Spaniel, Welsh Springer/Mix
Spaniel/Mix
Spanish Water Dog
Spitz
Spitz, Finnish
Spitz, Finnish/Mix
Spitz, German
Spitz, German/Mix
Spitz, Japanese
Spitz/Mix
Stabyhoun
Tahltan Bear Dog
Teddy Bear
Teddy Poo
Terrier
Terrier, Abyssinian Sand
Terrier, Airedale
Terrier, Airedale/Mix
Terrier, American Crested Sand
Terrier, American Hairless
Terrier, American Hairless/Mix
Terrier, American Pit Bull
Terrier, American Pit Bull/Mix
Terrier, American Staffordshire
Terrier, American Staffordshire/Mix
Terrier, Australian
Terrier, Australian/Mix
Terrier, Bedlington
Terrier, Bedlington/Mix
Terrier, Black Russian
Terrier, Border
Terrier, Border/Mix
Terrier, Boston
Terrier, Boston/Mix
Terrier, Brazilian
Terrier, Bull
Terrier, Bull, Miniature
Terrier, Bull, Miniature/Mix
Terrier, Bull/Mix
Terrier, Cairn
Terrier, Cairn/Mix
Terrier, Cesky
Terrier, Dandi Dinmont
Terrier, Fox
Terrier, Fox, Miniature
Terrier, Fox, Miniature/Mix
Terrier, Fox, Smooth
Terrier, Fox, Smooth/Mix
Terrier, Fox, Toy
Terrier, Fox, Toy/Mix
Terrier, Fox, Wire
Terrier, Fox/Mix
Terrier, Glen of Imaal
Terrier, Glen of Imaal/Mix
Terrier, Irish
Terrier, Irish/Mix
Terrier, Jack Russell
Terrier, Jack Russell Wirehaired
Terrier, Jack Russell/Mix
Terrier, Japanese
Terrier, Kerry Blue
Terrier, Lakeland
Terrier, Manchester
Terrier, Manchester, Toy
Terrier, Manchester/Mix
Terrier, Norfolk
Terrier, Norfolk/Mix
Terrier, Norwich
Terrier, Norwich/Mix
Terrier, Parson Russell
Terrier, Parson Russell/Mix
Terrier, Patterdale (Fell)
Terrier, Patterdale (Fell)/Mix
Terrier, Pit Bull
Terrier, Pit Bull/Mix
Terrier, Rat
Terrier, Rat/Mix
Terrier, Scottish Scottie
Terrier, Scottish Scottie/Mix
Terrier, Sealyham
Terrier, Silky
Terrier, Silky Australian
Terrier, Silky/Mix
Terrier, Skye
Terrier, Skye/Mix
Terrier, Soft Coated Wheaten
Terrier, Soft Coated Wheaten/Mix
Terrier, Staffordshire Bull
Terrier, Staffordshire Bull/Mix
Terrier, Tenterfield
Terrier, Tibetan
Terrier, Tibetan/Mix
Terrier, Welsh
Terrier, Welsh/Mix
Terrier, West Highland White Westie
Terrier, West Highland White Westie/Mix
Terrier, Wheaten
Terrier, Wire Fox
Terrier, Wire Fox/Mix
Terrier, Wirehaired
Terrier, Wirehaired/Mix
Terrier, Yorkshire, Yorkie
Terrier, Yorkshire, Yorkie/Mix
Terrier/Mix
Tosa Inu
Treeing Tennessee Brindle
Unknown
Vallhund, Swedish
Vallhund, Swedish/Mix
Vizsla
Vizsla, Hungarian
Vizsla, Smooth Haired
Vizsla, Smooth Haired/Mix
Vizsla, Wire Haired
Vizsla/Mix
Volpino Italiano
Weimaraner
Weimaraner/Mix
Whippet
Whippet/Mix
Wolf
Wolf, Hybrid
Wolf, Hybrid/Mix
Wolf/Mix
Wolfdog
Wolfdog, Czechoslovakian
Wolfdog, Czechoslovakian/Mix
Wolfdog, Saarloos
Wolfdog, Saarloos/aMix
Wolfdog/Mix
Wolfhound, Irish
Xoloitzcuintle (Mexican Hairless)
Xoloitzcuintle (Mexican Hairless)/Mix
89
Cat Breed
* Domestic Long Hair *
* Domestic Medium Hair *
* Domestic Short Hair *
Abyssinian
Abyssinian/Mix
American Bobtail
American Bobtail/Mix
American Curl
American Curl/Mix
American Shorthair
American Shorthair/Mix
American Wirehair
American Wirehair/Mix
Applehead Siamese
Balinese
Balinese/Mix
Bengal
Bengal/Mix
Birman
Birman/Mix
Bobtail
Bombay
Bombay/Mix
British Longhair
British Longhair/Mix
British Shorthair
British Shorthair/Mix
Burmese
Burmese/Mix
Burmilla
Calico
Calico/Mix
California Spangled
Canadian Hairless
Chantilly
Chartreux
Chartreux/Mix
Chausie
Chinchilla
Chinese Domestic
Colorpoint Shorthair
Colorpoint Shorthair/Mix
Cornish Rex
Cornish Rex/Mix
Cymric
Cymric/Mix
Desert Lynx
Devon Rex
Devon Rex/Mix
Dilute Calico
Dilute Tortoiseshell
Domestic Longhair/Mix
Domestic Medium Hair/Mix
Domestic Shorthair/Mix
Egyptian Mau
Egyptian Mau/Mix
European Shorthair
Exotic Longhair
Exotic Longhair/Mix
Exotic Shorthair
Exotic Shorthair/Mix
Extra-Toes Cat (Hemingway Polydactyl)
Extra-Toes Cat (Hemingway Polydactyl)/Mix
Feral
Havana Brown
Havana Brown/Mix
Highlander
Himalayan
Himalayan/Mix
Japanese Bobtail
Japanese Bobtail/Mix
Javanese
Javanese/Mix
Kashmir
Khao-Manee
Korat
Laperm
Maine Coon
Maine Coon/Mix
Manx
Manx/Mix
Mixed
Munchkin
Munchkin/Mix
Nebelung
Norwegian Forest Cat
Norwegian Forest Cat/Mix
Ocicat
Ocicat/Mix
Oriental Long Hair
Oriental Long Hair/Mix
Oriental Short Hair
Oriental Tabby
Persian
Persian/Mix
Pixie-Bob
Pixie-Bob/Mix
Ragamuffin
Ragamuffin/Mix
Ragdoll
Ragdoll/Mix
Russian Blue
Russian Blue/Mix
Savannah
Scottish Fold
Scottish Fold/Mix
Selkirk Rex
Selkirk Rex/Mix
Siamese
Siamese/Mix
Siberian
Siberian/Mix
Silver
Singapura
Singapura/Mix
Snowshoe
Snowshoe/Mix
Sokoke
Somali
Sphynx
Sphynx/Mix
Tabby
Tiger
Tonkinese
Tonkinese/Mix
Torbie
Tortoiseshell
Toyger
Turkish Angora
Turkish Angora/Mix
Turkish Van
Turkish Van/Mix
Tuxedo
Unknown
York Chocolate
90
Other Pet Species
91
Medical Event
92
Has this pet had their rabies vaccination?
Yes (Rabies)
No (Rabies)
93
Vaccine Name
94
Date of Vaccination
Please use XX/XX/XXXX format.
95
Where did they receive this vaccine?
96
What vet office does your pet use?
Put N/A if they do not have one.
97
Please list your pet's current medications, illnesses, injuries, or ailments.
98
Has your pet ever bitten anyone?* This field is required.
Yes
No
99
Please give us a brief description of the bite incident.
100
Add a photo of your pet
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Cancelof
101
Do you have a fourth pet?* This field is required.
Yes
No
102
Fourth Pet's Name
103
Type
Dog
Cat
Other
104
Age
105
Weight
106
Gender
Female
Female Spayed
Male
Male Neutered
Unknown
107
Dog Breed
* Mixed Breed Large (>45 Lbs Fully Grown) *
* Mixed Breed Med (25-44 Lbs Fully Grown) *
* Mixed Breed Small (<25 Lbs Fully Grown) *
Affenpinscher
Affenpinscher/Mix
Aidi
Ainu
Akbash
Akbash/Mix
Akita
Akita Inu
Akita/Mix
Alano Español
Alopekis
Alpine Dachsbracke
American Bully
American Bully/Mix
Appenzeller Sennenhunde
Armant
Azawakh
Bahamian Potcake
Barbet
Basenji
Basenji/Mix
Beagle
Beagle, Kerry
Beagle/Mix
Beauceron
Beauceron/Mix
Berger Picard
Bichon Frise
Bichon Frise/Mix
Blue Heeler
Blue Heeler, American
Blue Heeler, American/Mix
Blue Lacy
Blue Lacy/Mix
Boerboel
Boerboel/Mix
Bolognese
Bolognese/Mix
Bolonka
Borzoi
Borzoi/Mix
Bouvier des Ardennes
Bouvier Des Flandres
Bouvier Des Flandres/Mix
Boxer
Boxer/Mix
Bracco Italiano
Braque Francais, Gascogne
Braque Francais, Pyrenees
Brasileiro, Fila
Brasileiro, Fila/Mix
Briard
Briard/Mix
Bull Arab
Bull Arab/Mix
Bulldog
Bulldog, Alapaha Blue Blood
Bulldog, Alapaha Blue Blood/Mix
Bulldog, American
Bulldog, American/Mix
Bulldog, Australian
Bulldog, Australian/Mix
Bulldog, British
Bulldog, British/Mix
Bulldog, English
Bulldog, English/Mix
Bulldog, French
Bulldog, French/Mix
Bulldog, Johnson
Bulldog, Johnson/Mix
Bulldog, Old English
Bulldog, Old English/Mix
Bulldog, Victorian
Bulldog, Victorian/Mix
Bulldog/Mix
Bulldogge, Banter
Bulldogge, Banter/Mix
Cambodian Razorback Dog
Canaan Dog
Canaan Dog/Mix
Canario, Presa
Canario, Presa/Mix
Cane Di Oropa
Cane Toccatore
Carolina Dog
Carolina Dog/Mix
Castro Laboreiro Dog
Catahoula Leopard Dog
Catahoula Leopard Dog/Mix
Cattle Dog
Cattle Dog, Australian
Cattle Dog, Australian (Blue Heeler)
Cattle Dog, Australian (Blue Heeler)/Mix
Cattle Dog, Australian (Red Heeler)
Cattle Dog, Australian (Red Heeler)/Mix
Cattle Dog, Azores
Cattle Dog, Smithfield
Cattle Dog/Mix
Chihuahua
Chihuahua, Long Coat
Chihuahua, Long Coat/Mix
Chihuahua, Short Coat
Chihuahua, Short Coat/Mix
Chihuahua/Mix
Chinese Crested Dog
Chinese Crested Dog/Mix
Chinese Foo Dog
Chinese Shar-Pei
Chinese Shar-Pei/Mix
Chinook
Chow Chow
Chow Chow/Mix
Cimarrón Uruguayo
Cirneco Dell'etna
Cockapoo
Cockapoo/Mix
Collie
Collie, Bearded
Collie, Bearded/Mix
Collie, Border
Collie, Border/Mix
Collie, Rough
Collie, Rough/Mix
Collie, Smooth
Collie, Smooth/Mix
Collie/Mix
Coonhound
Coonhound, American English
Coonhound, Black and Tan
Coonhound, Black and Tan/Mix
Coonhound, Bluetick
Coonhound, Bluetick/Mix
Coonhound, English
Coonhound, English/Mix
Coonhound, Redbone
Coonhound, Redbone/Mix
Coonhound, Redtick
Coonhound, Treeing Walker
Coonhound, Treeing Walker/Mix
Coonhound/Mix
Corgi
Corgi, Cardigan Welsh
Corgi, Cardigan Welsh/Mix
Corgi, Pembroke Welsh
Corgi, Pembroke Welsh/Mix
Corgi, Welsh
Corgi/Mix
Coton De Tulear
Coton De Tulear/Mix
Coyote
Coyote, Hybrid
Coyote, Hybrid/Mix
Coyote/Mix
Cur, Black Mouth
Cur, Black Mouth/Mix
Cur, Mountain
Cur, Mountain/Mix
Dachshund
Dachshund, Miniature Long Haired
Dachshund, Miniature Long Haired/Mix
Dachshund, Miniature Smooth Haired
Dachshund, Miniature Smooth Haired/Mix
Dachshund, Miniature Wire Haired
Dachshund, Miniature Wire Haired/Mix
Dachshund, Standard Long Haired
Dachshund, Standard Long Haired/Mix
Dachshund, Standard Smooth Haired
Dachshund, Standard Smooth Haired/Mix
Dachshund, Standard Wire Haired
Dachshund, Standard Wire Haired/Mix
Dachshund/Mix
Dalmatian
Dalmatian/Mix
Damchi
Danish Broholmer
Dingo
Dingo/Mix
Dogo Argentino
Dogo Argentino/Mix
Dogue De Bordeaux
Dogue de Bordeaux/Mix
Doodle/Mix
Dosa Inu
Double Doodle
Drever
Dutch Smoushond
Elkhound, Norwegian
Elkhound, Norwegian/Mix
Elkhound, Swedish
Entlebucher
Eskimo Dog
Eskimo Dog/Mix
Eskimo, American
Eskimo, American/Mix
Eskimo, Canadian
Eurasier
Feist
Feist/Mix
Fox, Hybrid
Fox, Hybrid/Mix
Fox/Mix
Foxhound
Foxhound, American
Foxhound, American/Mix
Foxhound, English
Foxhound, English/Mix
Goldendoodle
Great Dane
Great Dane/Mix
Greenland Dog
Greyhound
Greyhound, Galgo Pinscher
Greyhound, Italian
Greyhound, Italian/Mix
Greyhound/Mix
Griffon Vendeen, Briquet
Griffon Vendeen, Grand Basset
Griffon Vendeen, Petit Basset
Griffon, Belgian
Griffon, Brussels
Griffon, Brussels/Mix
Griffon, Wire-Haired Pointing
Griffon, Wire-Haired Pointing/Mix
Harrier
Havanese
Havanese/Mix
Heeler, Lancashire
Heeler, Queensland
Heeler, Queensland/Mix
Hound
Hound, Afghan
Hound, Afghan/Mix
Hound, American Blue Gascon
Hound, Basset
Hound, Basset/Mix
Hound, Bloodhound
Hound, Bloodhound/Mix
Hound, Dunker
Hound, Halden (Haldenstover)
Hound, Hygen
Hound, Ibizan
Hound, Ibizan/Mix
Hound, Irish Wolfhound
Hound, Irish Wolfhound/Mix
Hound, Pharaoh
Hound, Pharaoh/Mix
Hound, Plott
Hound, Plott/Mix
Hound, Schweizer Laufhund
Hound, Scottish Deerhound
Hound, Staghound
Hound/Mix
Hovawart
Husky
Husky, Alaskan
Husky, Alaskan/Mix
Husky, Siberian
Husky, Siberian/Mix
Husky/Mix
Italian Spinone
Japanese Chin
Japanese Chin/Mix
Jindo
Jindo, Korean
Jindo, Korean/Mix
Kai Dog
Kai Dog/Mix
Karakachan
Karelian Bear Dog
Karelian Bear Dog/Mix
Keeshond
Keeshond/Mix
Kelpie
Kelpie, Australian
Kelpie, Australian/Mix
Kishu
Klee Kai
Klee Kai, Alaskan
Komondor
Kooikerhondje
Koolie, Australian
Koolie, German
Kromfohrlander, Smooth Coat
Kromfohrlander, Wire Haired
Kuvasz
Kuvasz/Mix
Kyi Leo
Labradoodle
Lagotto Romagnolo
Landseer
Lapphund, Finnish
Lapphund, Finnish/Mix
Leonberger
Leonberger/Mix
Lhasa Apso
Lhasa Apso/Mix
Löwchen
Lowchen/Mix
Malamute, Alaskan
Malamute, Alaskan/Mix
Maltese
Maltese/Mix
Maltipoo
Mastiff
Mastiff, Abruzzese
Mastiff, American Bandogge
Mastiff, American Bandogge/Mix
Mastiff, Bullmastiff
Mastiff, Bullmastiff/Mix
Mastiff, Cane Corso
Mastiff, Cane Corso/Mix
Mastiff, English
Mastiff, English/Mix
Mastiff, Korean
Mastiff, Neapolitan
Mastiff, Neapolitan/Mix
Mastiff, Tibetan
Mastiff, Tibetan/Mix
Mastiff/Mix
Mixed
Mountain Dog
Mountain Dog, Appenzell
Mountain Dog, Appenzell/Mix
Mountain Dog, Bernese
Mountain Dog, Bernese/Mix
Mountain Dog, Estrela
Mountain Dog, Greater Swiss
Mountain Dog, Greater Swiss/Mix
Mountain Dog, Taiwanese
Mudi
Münsterländer
Native American Indian Dog
New Guinea Singing Dog
Newfoundland
Newfoundland/Mix
Norrbottenspets
Norwegian Buhund
Norwegian Buhund/Mix
Norwegian Lundehund
Nureongi
Otterhound
Otterhound/Mix
Papillon
Papillon/Mix
Pekingese
Pekingese/Mix
Perdigueiro Galego
Peruvian Inca Orchid
Pinscher
Pinscher, Austrian
Pinscher, Austrian/Mix
Pinscher, Doberman
Pinscher, Doberman/Mix
Pinscher, German
Pinscher, German/Mix
Pinscher, Miniature
Pinscher, Miniature/Mix
Podenco Canario
Podengo Portugueso
Pointer
Pointer, English
Pointer, German Longhaired
Pointer, German Shorthaired
Pointer, German Shorthaired/Mix
Pointer, German Wirehaired
Pointer, German Wirehaired/Mix
Pointer, Podenco Galego
Pointer/Mix
Pomeranian
Pomeranian/Mix
Poodle
Poodle, Miniature
Poodle, Miniature/Mix
Poodle, Standard
Poodle, Standard/Mix
Poodle, Toy
Poodle, Toy/Mix
Poodle/Mix
Portuguese Water Dog
Portuguese Water Dog/Mix
Pudelpointer
Pug
Pug, American Lo-Sze
Pug/Mix
Puggle
Puli
Pumi
Pungsan
Pyrenees, Great
Pyrenees, Great/Mix
Rafeiro do Alentejo
Retriever
Retriever, Black Labrador
Retriever, Black Labrador/Mix
Retriever, Chesapeake Bay
Retriever, Chesapeake Bay/Mix
Retriever, Chocolate Labrador
Retriever, Chocolate Labrador/Mix
Retriever, Curly-Coated
Retriever, Curly-Coated/Mix
Retriever, Flat-Coated
Retriever, Flat-Coated/Mix
Retriever, Golden
Retriever, Golden/Mix
Retriever, Labrador
Retriever, Labrador/Mix
Retriever, Nova Scotia Duck-Tolling
Retriever, Nova Scotia Duck-Tolling/Mix
Retriever, Yellow Labrador
Retriever, Yellow Labrador/Mix
Retriever/Mix
Ridgeback, Rhodesian
Ridgeback, Rhodesian/Mix
Ridgeback, Thai
Ridgeback, Thai/Mix
Rottweiler
Rottweiler/Mix
Saint Bernard
Saint Bernard/Mix
Saluki
Saluki/Mix
Samoyed
Samoyed/Mix
Schipperke
Schipperke/Mix
Schnauzer
Schnauzer, Giant
Schnauzer, Giant/Mix
Schnauzer, Miniature
Schnauzer, Miniature/Mix
Schnauzer, Standard
Schnauzer, Standard/Mix
Schnauzer/Mix
Setter
Setter, English
Setter, English/Mix
Setter, Gordon
Setter, Gordon/Mix
Setter, Irish
Setter, Irish Red and White
Setter, Irish/Mix
Shar Pei
Shar Pei/Mix
Sheepdog
Sheepdog, Bergamasco
Sheepdog, Caucasian Ovtcharka
Sheepdog, Croatian
Sheepdog, Dutch
Sheepdog, Icelandic
Sheepdog, Illyrian
Sheepdog, Maremma
Sheepdog, Mcnab
Sheepdog, Mcnab/Mix
Sheepdog, Old English
Sheepdog, Old English/Mix
Sheepdog, Picardy
Sheepdog, Polish Lowland
Sheepdog, Polish Lowland/Mix
Sheepdog, Portuguese
Sheepdog, Shetland
Sheepdog, Shetland/Mix
Sheepdog/Mix
Shepherd
Shepherd, Anatolian
Shepherd, Anatolian/Mix
Shepherd, Australian
Shepherd, Australian, Miniature
Shepherd, Australian/Mix
Shepherd, Belgian Groenendael
Shepherd, Belgian Laekenois
Shepherd, Belgian Malinois
Shepherd, Belgian Malinois/Mix
Shepherd, Belgian Sheepdog
Shepherd, Belgian Sheepdog/Mix
Shepherd, Belgian Tervuren
Shepherd, Belgian Tervuren/Mix
Shepherd, Carpathian
Shepherd, Central Asian
Shepherd, Dutch
Shepherd, Dutch/Mix
Shepherd, English
Shepherd, English/Mix
Shepherd, German
Shepherd, German King
Shepherd, German King/Mix
Shepherd, German/Mix
Shepherd, Miniature
Shepherd, Pyrenean
Shepherd, Shiloh
Shepherd, White German
Shepherd, White German/Mix
Shepherd, White Swiss (Berger Blanc Suisse)
Shepherd/Mix
Shiba Inu
Shiba Inu/Mix
Shih Tzu
Shih Tzu/Mix
Silken Windhound
Sloughi
South Russian Ovcharkas
Spaniel
Spaniel, American Cocker
Spaniel, American Cocker/Mix
Spaniel, American Water
Spaniel, American Water/Mix
Spaniel, Boykin
Spaniel, Brittany
Spaniel, Brittany, French
Spaniel, Brittany/Mix
Spaniel, Cavalier King Charles
Spaniel, Cavalier King Charles/Mix
Spaniel, Clumber
Spaniel, Clumber/Mix
Spaniel, Cocker
Spaniel, Cocker/Mix
Spaniel, English Cocker
Spaniel, English Cocker/Mix
Spaniel, English Springer
Spaniel, English Springer/Mix
Spaniel, English Toy
Spaniel, English Toy/Mix
Spaniel, Field
Spaniel, French
Spaniel, Irish Water
Spaniel, Springer
Spaniel, Sussex
Spaniel, Sussex/Mix
Spaniel, Swedish
Spaniel, Tibetan
Spaniel, Tibetan/Mix
Spaniel, Welsh Springer
Spaniel, Welsh Springer/Mix
Spaniel/Mix
Spanish Water Dog
Spitz
Spitz, Finnish
Spitz, Finnish/Mix
Spitz, German
Spitz, German/Mix
Spitz, Japanese
Spitz/Mix
Stabyhoun
Tahltan Bear Dog
Teddy Bear
Teddy Poo
Terrier
Terrier, Abyssinian Sand
Terrier, Airedale
Terrier, Airedale/Mix
Terrier, American Crested Sand
Terrier, American Hairless
Terrier, American Hairless/Mix
Terrier, American Pit Bull
Terrier, American Pit Bull/Mix
Terrier, American Staffordshire
Terrier, American Staffordshire/Mix
Terrier, Australian
Terrier, Australian/Mix
Terrier, Bedlington
Terrier, Bedlington/Mix
Terrier, Black Russian
Terrier, Border
Terrier, Border/Mix
Terrier, Boston
Terrier, Boston/Mix
Terrier, Brazilian
Terrier, Bull
Terrier, Bull, Miniature
Terrier, Bull, Miniature/Mix
Terrier, Bull/Mix
Terrier, Cairn
Terrier, Cairn/Mix
Terrier, Cesky
Terrier, Dandi Dinmont
Terrier, Fox
Terrier, Fox, Miniature
Terrier, Fox, Miniature/Mix
Terrier, Fox, Smooth
Terrier, Fox, Smooth/Mix
Terrier, Fox, Toy
Terrier, Fox, Toy/Mix
Terrier, Fox, Wire
Terrier, Fox/Mix
Terrier, Glen of Imaal
Terrier, Glen of Imaal/Mix
Terrier, Irish
Terrier, Irish/Mix
Terrier, Jack Russell
Terrier, Jack Russell Wirehaired
Terrier, Jack Russell/Mix
Terrier, Japanese
Terrier, Kerry Blue
Terrier, Lakeland
Terrier, Manchester
Terrier, Manchester, Toy
Terrier, Manchester/Mix
Terrier, Norfolk
Terrier, Norfolk/Mix
Terrier, Norwich
Terrier, Norwich/Mix
Terrier, Parson Russell
Terrier, Parson Russell/Mix
Terrier, Patterdale (Fell)
Terrier, Patterdale (Fell)/Mix
Terrier, Pit Bull
Terrier, Pit Bull/Mix
Terrier, Rat
Terrier, Rat/Mix
Terrier, Scottish Scottie
Terrier, Scottish Scottie/Mix
Terrier, Sealyham
Terrier, Silky
Terrier, Silky Australian
Terrier, Silky/Mix
Terrier, Skye
Terrier, Skye/Mix
Terrier, Soft Coated Wheaten
Terrier, Soft Coated Wheaten/Mix
Terrier, Staffordshire Bull
Terrier, Staffordshire Bull/Mix
Terrier, Tenterfield
Terrier, Tibetan
Terrier, Tibetan/Mix
Terrier, Welsh
Terrier, Welsh/Mix
Terrier, West Highland White Westie
Terrier, West Highland White Westie/Mix
Terrier, Wheaten
Terrier, Wire Fox
Terrier, Wire Fox/Mix
Terrier, Wirehaired
Terrier, Wirehaired/Mix
Terrier, Yorkshire, Yorkie
Terrier, Yorkshire, Yorkie/Mix
Terrier/Mix
Tosa Inu
Treeing Tennessee Brindle
Unknown
Vallhund, Swedish
Vallhund, Swedish/Mix
Vizsla
Vizsla, Hungarian
Vizsla, Smooth Haired
Vizsla, Smooth Haired/Mix
Vizsla, Wire Haired
Vizsla/Mix
Volpino Italiano
Weimaraner
Weimaraner/Mix
Whippet
Whippet/Mix
Wolf
Wolf, Hybrid
Wolf, Hybrid/Mix
Wolf/Mix
Wolfdog
Wolfdog, Czechoslovakian
Wolfdog, Czechoslovakian/Mix
Wolfdog, Saarloos
Wolfdog, Saarloos/aMix
Wolfdog/Mix
Wolfhound, Irish
Xoloitzcuintle (Mexican Hairless)
Xoloitzcuintle (Mexican Hairless)/Mix
108
Cat Breed
* Domestic Long Hair *
* Domestic Medium Hair *
* Domestic Short Hair *
Abyssinian
Abyssinian/Mix
American Bobtail
American Bobtail/Mix
American Curl
American Curl/Mix
American Shorthair
American Shorthair/Mix
American Wirehair
American Wirehair/Mix
Applehead Siamese
Balinese
Balinese/Mix
Bengal
Bengal/Mix
Birman
Birman/Mix
Bobtail
Bombay
Bombay/Mix
British Longhair
British Longhair/Mix
British Shorthair
British Shorthair/Mix
Burmese
Burmese/Mix
Burmilla
Calico
Calico/Mix
California Spangled
Canadian Hairless
Chantilly
Chartreux
Chartreux/Mix
Chausie
Chinchilla
Chinese Domestic
Colorpoint Shorthair
Colorpoint Shorthair/Mix
Cornish Rex
Cornish Rex/Mix
Cymric
Cymric/Mix
Desert Lynx
Devon Rex
Devon Rex/Mix
Dilute Calico
Dilute Tortoiseshell
Domestic Longhair/Mix
Domestic Medium Hair/Mix
Domestic Shorthair/Mix
Egyptian Mau
Egyptian Mau/Mix
European Shorthair
Exotic Longhair
Exotic Longhair/Mix
Exotic Shorthair
Exotic Shorthair/Mix
Extra-Toes Cat (Hemingway Polydactyl)
Extra-Toes Cat (Hemingway Polydactyl)/Mix
Feral
Havana Brown
Havana Brown/Mix
Highlander
Himalayan
Himalayan/Mix
Japanese Bobtail
Japanese Bobtail/Mix
Javanese
Javanese/Mix
Kashmir
Khao-Manee
Korat
Laperm
Maine Coon
Maine Coon/Mix
Manx
Manx/Mix
Mixed
Munchkin
Munchkin/Mix
Nebelung
Norwegian Forest Cat
Norwegian Forest Cat/Mix
Ocicat
Ocicat/Mix
Oriental Long Hair
Oriental Long Hair/Mix
Oriental Short Hair
Oriental Tabby
Persian
Persian/Mix
Pixie-Bob
Pixie-Bob/Mix
Ragamuffin
Ragamuffin/Mix
Ragdoll
Ragdoll/Mix
Russian Blue
Russian Blue/Mix
Savannah
Scottish Fold
Scottish Fold/Mix
Selkirk Rex
Selkirk Rex/Mix
Siamese
Siamese/Mix
Siberian
Siberian/Mix
Silver
Singapura
Singapura/Mix
Snowshoe
Snowshoe/Mix
Sokoke
Somali
Sphynx
Sphynx/Mix
Tabby
Tiger
Tonkinese
Tonkinese/Mix
Torbie
Tortoiseshell
Toyger
Turkish Angora
Turkish Angora/Mix
Turkish Van
Turkish Van/Mix
Tuxedo
Unknown
York Chocolate
109
Other Pet Species
110
Medical Event
111
Has this pet had their rabies vaccination?
Yes (Rabies)
No (Rabies)
112
Vaccine Name
113
Date of Vaccination
Please use XX/XX/XXXX format.
114
Where did they receive this vaccine?
115
What vet office does your pet use?
Put N/A if they do not have one.
116
Please list your pet's current medications, illnesses, injuries, or ailments.
117
Has your pet ever bitten anyone?* This field is required.
Yes
No
118
Please give us a brief description of the bite incident.
119
Add a photo of your pet
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Select files to upload
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Cancelof
120
Do you have a fifth pet?* This field is required.
Yes
No
121
Fifth Pet's Name
122
Type
Dog
Cat
Other
123
Age
124
Weight
125
Gender
Female
Female Spayed
Male
Male Neutered
Unknown
126
Dog Breed
* Mixed Breed Large (>45 Lbs Fully Grown) *
* Mixed Breed Med (25-44 Lbs Fully Grown) *
* Mixed Breed Small (<25 Lbs Fully Grown) *
Affenpinscher
Affenpinscher/Mix
Aidi
Ainu
Akbash
Akbash/Mix
Akita
Akita Inu
Akita/Mix
Alano Español
Alopekis
Alpine Dachsbracke
American Bully
American Bully/Mix
Appenzeller Sennenhunde
Armant
Azawakh
Bahamian Potcake
Barbet
Basenji
Basenji/Mix
Beagle
Beagle, Kerry
Beagle/Mix
Beauceron
Beauceron/Mix
Berger Picard
Bichon Frise
Bichon Frise/Mix
Blue Heeler
Blue Heeler, American
Blue Heeler, American/Mix
Blue Lacy
Blue Lacy/Mix
Boerboel
Boerboel/Mix
Bolognese
Bolognese/Mix
Bolonka
Borzoi
Borzoi/Mix
Bouvier des Ardennes
Bouvier Des Flandres
Bouvier Des Flandres/Mix
Boxer
Boxer/Mix
Bracco Italiano
Braque Francais, Gascogne
Braque Francais, Pyrenees
Brasileiro, Fila
Brasileiro, Fila/Mix
Briard
Briard/Mix
Bull Arab
Bull Arab/Mix
Bulldog
Bulldog, Alapaha Blue Blood
Bulldog, Alapaha Blue Blood/Mix
Bulldog, American
Bulldog, American/Mix
Bulldog, Australian
Bulldog, Australian/Mix
Bulldog, British
Bulldog, British/Mix
Bulldog, English
Bulldog, English/Mix
Bulldog, French
Bulldog, French/Mix
Bulldog, Johnson
Bulldog, Johnson/Mix
Bulldog, Old English
Bulldog, Old English/Mix
Bulldog, Victorian
Bulldog, Victorian/Mix
Bulldog/Mix
Bulldogge, Banter
Bulldogge, Banter/Mix
Cambodian Razorback Dog
Canaan Dog
Canaan Dog/Mix
Canario, Presa
Canario, Presa/Mix
Cane Di Oropa
Cane Toccatore
Carolina Dog
Carolina Dog/Mix
Castro Laboreiro Dog
Catahoula Leopard Dog
Catahoula Leopard Dog/Mix
Cattle Dog
Cattle Dog, Australian
Cattle Dog, Australian (Blue Heeler)
Cattle Dog, Australian (Blue Heeler)/Mix
Cattle Dog, Australian (Red Heeler)
Cattle Dog, Australian (Red Heeler)/Mix
Cattle Dog, Azores
Cattle Dog, Smithfield
Cattle Dog/Mix
Chihuahua
Chihuahua, Long Coat
Chihuahua, Long Coat/Mix
Chihuahua, Short Coat
Chihuahua, Short Coat/Mix
Chihuahua/Mix
Chinese Crested Dog
Chinese Crested Dog/Mix
Chinese Foo Dog
Chinese Shar-Pei
Chinese Shar-Pei/Mix
Chinook
Chow Chow
Chow Chow/Mix
Cimarrón Uruguayo
Cirneco Dell'etna
Cockapoo
Cockapoo/Mix
Collie
Collie, Bearded
Collie, Bearded/Mix
Collie, Border
Collie, Border/Mix
Collie, Rough
Collie, Rough/Mix
Collie, Smooth
Collie, Smooth/Mix
Collie/Mix
Coonhound
Coonhound, American English
Coonhound, Black and Tan
Coonhound, Black and Tan/Mix
Coonhound, Bluetick
Coonhound, Bluetick/Mix
Coonhound, English
Coonhound, English/Mix
Coonhound, Redbone
Coonhound, Redbone/Mix
Coonhound, Redtick
Coonhound, Treeing Walker
Coonhound, Treeing Walker/Mix
Coonhound/Mix
Corgi
Corgi, Cardigan Welsh
Corgi, Cardigan Welsh/Mix
Corgi, Pembroke Welsh
Corgi, Pembroke Welsh/Mix
Corgi, Welsh
Corgi/Mix
Coton De Tulear
Coton De Tulear/Mix
Coyote
Coyote, Hybrid
Coyote, Hybrid/Mix
Coyote/Mix
Cur, Black Mouth
Cur, Black Mouth/Mix
Cur, Mountain
Cur, Mountain/Mix
Dachshund
Dachshund, Miniature Long Haired
Dachshund, Miniature Long Haired/Mix
Dachshund, Miniature Smooth Haired
Dachshund, Miniature Smooth Haired/Mix
Dachshund, Miniature Wire Haired
Dachshund, Miniature Wire Haired/Mix
Dachshund, Standard Long Haired
Dachshund, Standard Long Haired/Mix
Dachshund, Standard Smooth Haired
Dachshund, Standard Smooth Haired/Mix
Dachshund, Standard Wire Haired
Dachshund, Standard Wire Haired/Mix
Dachshund/Mix
Dalmatian
Dalmatian/Mix
Damchi
Danish Broholmer
Dingo
Dingo/Mix
Dogo Argentino
Dogo Argentino/Mix
Dogue De Bordeaux
Dogue de Bordeaux/Mix
Doodle/Mix
Dosa Inu
Double Doodle
Drever
Dutch Smoushond
Elkhound, Norwegian
Elkhound, Norwegian/Mix
Elkhound, Swedish
Entlebucher
Eskimo Dog
Eskimo Dog/Mix
Eskimo, American
Eskimo, American/Mix
Eskimo, Canadian
Eurasier
Feist
Feist/Mix
Fox, Hybrid
Fox, Hybrid/Mix
Fox/Mix
Foxhound
Foxhound, American
Foxhound, American/Mix
Foxhound, English
Foxhound, English/Mix
Goldendoodle
Great Dane
Great Dane/Mix
Greenland Dog
Greyhound
Greyhound, Galgo Pinscher
Greyhound, Italian
Greyhound, Italian/Mix
Greyhound/Mix
Griffon Vendeen, Briquet
Griffon Vendeen, Grand Basset
Griffon Vendeen, Petit Basset
Griffon, Belgian
Griffon, Brussels
Griffon, Brussels/Mix
Griffon, Wire-Haired Pointing
Griffon, Wire-Haired Pointing/Mix
Harrier
Havanese
Havanese/Mix
Heeler, Lancashire
Heeler, Queensland
Heeler, Queensland/Mix
Hound
Hound, Afghan
Hound, Afghan/Mix
Hound, American Blue Gascon
Hound, Basset
Hound, Basset/Mix
Hound, Bloodhound
Hound, Bloodhound/Mix
Hound, Dunker
Hound, Halden (Haldenstover)
Hound, Hygen
Hound, Ibizan
Hound, Ibizan/Mix
Hound, Irish Wolfhound
Hound, Irish Wolfhound/Mix
Hound, Pharaoh
Hound, Pharaoh/Mix
Hound, Plott
Hound, Plott/Mix
Hound, Schweizer Laufhund
Hound, Scottish Deerhound
Hound, Staghound
Hound/Mix
Hovawart
Husky
Husky, Alaskan
Husky, Alaskan/Mix
Husky, Siberian
Husky, Siberian/Mix
Husky/Mix
Italian Spinone
Japanese Chin
Japanese Chin/Mix
Jindo
Jindo, Korean
Jindo, Korean/Mix
Kai Dog
Kai Dog/Mix
Karakachan
Karelian Bear Dog
Karelian Bear Dog/Mix
Keeshond
Keeshond/Mix
Kelpie
Kelpie, Australian
Kelpie, Australian/Mix
Kishu
Klee Kai
Klee Kai, Alaskan
Komondor
Kooikerhondje
Koolie, Australian
Koolie, German
Kromfohrlander, Smooth Coat
Kromfohrlander, Wire Haired
Kuvasz
Kuvasz/Mix
Kyi Leo
Labradoodle
Lagotto Romagnolo
Landseer
Lapphund, Finnish
Lapphund, Finnish/Mix
Leonberger
Leonberger/Mix
Lhasa Apso
Lhasa Apso/Mix
Löwchen
Lowchen/Mix
Malamute, Alaskan
Malamute, Alaskan/Mix
Maltese
Maltese/Mix
Maltipoo
Mastiff
Mastiff, Abruzzese
Mastiff, American Bandogge
Mastiff, American Bandogge/Mix
Mastiff, Bullmastiff
Mastiff, Bullmastiff/Mix
Mastiff, Cane Corso
Mastiff, Cane Corso/Mix
Mastiff, English
Mastiff, English/Mix
Mastiff, Korean
Mastiff, Neapolitan
Mastiff, Neapolitan/Mix
Mastiff, Tibetan
Mastiff, Tibetan/Mix
Mastiff/Mix
Mixed
Mountain Dog
Mountain Dog, Appenzell
Mountain Dog, Appenzell/Mix
Mountain Dog, Bernese
Mountain Dog, Bernese/Mix
Mountain Dog, Estrela
Mountain Dog, Greater Swiss
Mountain Dog, Greater Swiss/Mix
Mountain Dog, Taiwanese
Mudi
Münsterländer
Native American Indian Dog
New Guinea Singing Dog
Newfoundland
Newfoundland/Mix
Norrbottenspets
Norwegian Buhund
Norwegian Buhund/Mix
Norwegian Lundehund
Nureongi
Otterhound
Otterhound/Mix
Papillon
Papillon/Mix
Pekingese
Pekingese/Mix
Perdigueiro Galego
Peruvian Inca Orchid
Pinscher
Pinscher, Austrian
Pinscher, Austrian/Mix
Pinscher, Doberman
Pinscher, Doberman/Mix
Pinscher, German
Pinscher, German/Mix
Pinscher, Miniature
Pinscher, Miniature/Mix
Podenco Canario
Podengo Portugueso
Pointer
Pointer, English
Pointer, German Longhaired
Pointer, German Shorthaired
Pointer, German Shorthaired/Mix
Pointer, German Wirehaired
Pointer, German Wirehaired/Mix
Pointer, Podenco Galego
Pointer/Mix
Pomeranian
Pomeranian/Mix
Poodle
Poodle, Miniature
Poodle, Miniature/Mix
Poodle, Standard
Poodle, Standard/Mix
Poodle, Toy
Poodle, Toy/Mix
Poodle/Mix
Portuguese Water Dog
Portuguese Water Dog/Mix
Pudelpointer
Pug
Pug, American Lo-Sze
Pug/Mix
Puggle
Puli
Pumi
Pungsan
Pyrenees, Great
Pyrenees, Great/Mix
Rafeiro do Alentejo
Retriever
Retriever, Black Labrador
Retriever, Black Labrador/Mix
Retriever, Chesapeake Bay
Retriever, Chesapeake Bay/Mix
Retriever, Chocolate Labrador
Retriever, Chocolate Labrador/Mix
Retriever, Curly-Coated
Retriever, Curly-Coated/Mix
Retriever, Flat-Coated
Retriever, Flat-Coated/Mix
Retriever, Golden
Retriever, Golden/Mix
Retriever, Labrador
Retriever, Labrador/Mix
Retriever, Nova Scotia Duck-Tolling
Retriever, Nova Scotia Duck-Tolling/Mix
Retriever, Yellow Labrador
Retriever, Yellow Labrador/Mix
Retriever/Mix
Ridgeback, Rhodesian
Ridgeback, Rhodesian/Mix
Ridgeback, Thai
Ridgeback, Thai/Mix
Rottweiler
Rottweiler/Mix
Saint Bernard
Saint Bernard/Mix
Saluki
Saluki/Mix
Samoyed
Samoyed/Mix
Schipperke
Schipperke/Mix
Schnauzer
Schnauzer, Giant
Schnauzer, Giant/Mix
Schnauzer, Miniature
Schnauzer, Miniature/Mix
Schnauzer, Standard
Schnauzer, Standard/Mix
Schnauzer/Mix
Setter
Setter, English
Setter, English/Mix
Setter, Gordon
Setter, Gordon/Mix
Setter, Irish
Setter, Irish Red and White
Setter, Irish/Mix
Shar Pei
Shar Pei/Mix
Sheepdog
Sheepdog, Bergamasco
Sheepdog, Caucasian Ovtcharka
Sheepdog, Croatian
Sheepdog, Dutch
Sheepdog, Icelandic
Sheepdog, Illyrian
Sheepdog, Maremma
Sheepdog, Mcnab
Sheepdog, Mcnab/Mix
Sheepdog, Old English
Sheepdog, Old English/Mix
Sheepdog, Picardy
Sheepdog, Polish Lowland
Sheepdog, Polish Lowland/Mix
Sheepdog, Portuguese
Sheepdog, Shetland
Sheepdog, Shetland/Mix
Sheepdog/Mix
Shepherd
Shepherd, Anatolian
Shepherd, Anatolian/Mix
Shepherd, Australian
Shepherd, Australian, Miniature
Shepherd, Australian/Mix
Shepherd, Belgian Groenendael
Shepherd, Belgian Laekenois
Shepherd, Belgian Malinois
Shepherd, Belgian Malinois/Mix
Shepherd, Belgian Sheepdog
Shepherd, Belgian Sheepdog/Mix
Shepherd, Belgian Tervuren
Shepherd, Belgian Tervuren/Mix
Shepherd, Carpathian
Shepherd, Central Asian
Shepherd, Dutch
Shepherd, Dutch/Mix
Shepherd, English
Shepherd, English/Mix
Shepherd, German
Shepherd, German King
Shepherd, German King/Mix
Shepherd, German/Mix
Shepherd, Miniature
Shepherd, Pyrenean
Shepherd, Shiloh
Shepherd, White German
Shepherd, White German/Mix
Shepherd, White Swiss (Berger Blanc Suisse)
Shepherd/Mix
Shiba Inu
Shiba Inu/Mix
Shih Tzu
Shih Tzu/Mix
Silken Windhound
Sloughi
South Russian Ovcharkas
Spaniel
Spaniel, American Cocker
Spaniel, American Cocker/Mix
Spaniel, American Water
Spaniel, American Water/Mix
Spaniel, Boykin
Spaniel, Brittany
Spaniel, Brittany, French
Spaniel, Brittany/Mix
Spaniel, Cavalier King Charles
Spaniel, Cavalier King Charles/Mix
Spaniel, Clumber
Spaniel, Clumber/Mix
Spaniel, Cocker
Spaniel, Cocker/Mix
Spaniel, English Cocker
Spaniel, English Cocker/Mix
Spaniel, English Springer
Spaniel, English Springer/Mix
Spaniel, English Toy
Spaniel, English Toy/Mix
Spaniel, Field
Spaniel, French
Spaniel, Irish Water
Spaniel, Springer
Spaniel, Sussex
Spaniel, Sussex/Mix
Spaniel, Swedish
Spaniel, Tibetan
Spaniel, Tibetan/Mix
Spaniel, Welsh Springer
Spaniel, Welsh Springer/Mix
Spaniel/Mix
Spanish Water Dog
Spitz
Spitz, Finnish
Spitz, Finnish/Mix
Spitz, German
Spitz, German/Mix
Spitz, Japanese
Spitz/Mix
Stabyhoun
Tahltan Bear Dog
Teddy Bear
Teddy Poo
Terrier
Terrier, Abyssinian Sand
Terrier, Airedale
Terrier, Airedale/Mix
Terrier, American Crested Sand
Terrier, American Hairless
Terrier, American Hairless/Mix
Terrier, American Pit Bull
Terrier, American Pit Bull/Mix
Terrier, American Staffordshire
Terrier, American Staffordshire/Mix
Terrier, Australian
Terrier, Australian/Mix
Terrier, Bedlington
Terrier, Bedlington/Mix
Terrier, Black Russian
Terrier, Border
Terrier, Border/Mix
Terrier, Boston
Terrier, Boston/Mix
Terrier, Brazilian
Terrier, Bull
Terrier, Bull, Miniature
Terrier, Bull, Miniature/Mix
Terrier, Bull/Mix
Terrier, Cairn
Terrier, Cairn/Mix
Terrier, Cesky
Terrier, Dandi Dinmont
Terrier, Fox
Terrier, Fox, Miniature
Terrier, Fox, Miniature/Mix
Terrier, Fox, Smooth
Terrier, Fox, Smooth/Mix
Terrier, Fox, Toy
Terrier, Fox, Toy/Mix
Terrier, Fox, Wire
Terrier, Fox/Mix
Terrier, Glen of Imaal
Terrier, Glen of Imaal/Mix
Terrier, Irish
Terrier, Irish/Mix
Terrier, Jack Russell
Terrier, Jack Russell Wirehaired
Terrier, Jack Russell/Mix
Terrier, Japanese
Terrier, Kerry Blue
Terrier, Lakeland
Terrier, Manchester
Terrier, Manchester, Toy
Terrier, Manchester/Mix
Terrier, Norfolk
Terrier, Norfolk/Mix
Terrier, Norwich
Terrier, Norwich/Mix
Terrier, Parson Russell
Terrier, Parson Russell/Mix
Terrier, Patterdale (Fell)
Terrier, Patterdale (Fell)/Mix
Terrier, Pit Bull
Terrier, Pit Bull/Mix
Terrier, Rat
Terrier, Rat/Mix
Terrier, Scottish Scottie
Terrier, Scottish Scottie/Mix
Terrier, Sealyham
Terrier, Silky
Terrier, Silky Australian
Terrier, Silky/Mix
Terrier, Skye
Terrier, Skye/Mix
Terrier, Soft Coated Wheaten
Terrier, Soft Coated Wheaten/Mix
Terrier, Staffordshire Bull
Terrier, Staffordshire Bull/Mix
Terrier, Tenterfield
Terrier, Tibetan
Terrier, Tibetan/Mix
Terrier, Welsh
Terrier, Welsh/Mix
Terrier, West Highland White Westie
Terrier, West Highland White Westie/Mix
Terrier, Wheaten
Terrier, Wire Fox
Terrier, Wire Fox/Mix
Terrier, Wirehaired
Terrier, Wirehaired/Mix
Terrier, Yorkshire, Yorkie
Terrier, Yorkshire, Yorkie/Mix
Terrier/Mix
Tosa Inu
Treeing Tennessee Brindle
Unknown
Vallhund, Swedish
Vallhund, Swedish/Mix
Vizsla
Vizsla, Hungarian
Vizsla, Smooth Haired
Vizsla, Smooth Haired/Mix
Vizsla, Wire Haired
Vizsla/Mix
Volpino Italiano
Weimaraner
Weimaraner/Mix
Whippet
Whippet/Mix
Wolf
Wolf, Hybrid
Wolf, Hybrid/Mix
Wolf/Mix
Wolfdog
Wolfdog, Czechoslovakian
Wolfdog, Czechoslovakian/Mix
Wolfdog, Saarloos
Wolfdog, Saarloos/aMix
Wolfdog/Mix
Wolfhound, Irish
Xoloitzcuintle (Mexican Hairless)
Xoloitzcuintle (Mexican Hairless)/Mix
127
Cat Breed
* Domestic Long Hair *
* Domestic Medium Hair *
* Domestic Short Hair *
Abyssinian
Abyssinian/Mix
American Bobtail
American Bobtail/Mix
American Curl
American Curl/Mix
American Shorthair
American Shorthair/Mix
American Wirehair
American Wirehair/Mix
Applehead Siamese
Balinese
Balinese/Mix
Bengal
Bengal/Mix
Birman
Birman/Mix
Bobtail
Bombay
Bombay/Mix
British Longhair
British Longhair/Mix
British Shorthair
British Shorthair/Mix
Burmese
Burmese/Mix
Burmilla
Calico
Calico/Mix
California Spangled
Canadian Hairless
Chantilly
Chartreux
Chartreux/Mix
Chausie
Chinchilla
Chinese Domestic
Colorpoint Shorthair
Colorpoint Shorthair/Mix
Cornish Rex
Cornish Rex/Mix
Cymric
Cymric/Mix
Desert Lynx
Devon Rex
Devon Rex/Mix
Dilute Calico
Dilute Tortoiseshell
Domestic Longhair/Mix
Domestic Medium Hair/Mix
Domestic Shorthair/Mix
Egyptian Mau
Egyptian Mau/Mix
European Shorthair
Exotic Longhair
Exotic Longhair/Mix
Exotic Shorthair
Exotic Shorthair/Mix
Extra-Toes Cat (Hemingway Polydactyl)
Extra-Toes Cat (Hemingway Polydactyl)/Mix
Feral
Havana Brown
Havana Brown/Mix
Highlander
Himalayan
Himalayan/Mix
Japanese Bobtail
Japanese Bobtail/Mix
Javanese
Javanese/Mix
Kashmir
Khao-Manee
Korat
Laperm
Maine Coon
Maine Coon/Mix
Manx
Manx/Mix
Mixed
Munchkin
Munchkin/Mix
Nebelung
Norwegian Forest Cat
Norwegian Forest Cat/Mix
Ocicat
Ocicat/Mix
Oriental Long Hair
Oriental Long Hair/Mix
Oriental Short Hair
Oriental Tabby
Persian
Persian/Mix
Pixie-Bob
Pixie-Bob/Mix
Ragamuffin
Ragamuffin/Mix
Ragdoll
Ragdoll/Mix
Russian Blue
Russian Blue/Mix
Savannah
Scottish Fold
Scottish Fold/Mix
Selkirk Rex
Selkirk Rex/Mix
Siamese
Siamese/Mix
Siberian
Siberian/Mix
Silver
Singapura
Singapura/Mix
Snowshoe
Snowshoe/Mix
Sokoke
Somali
Sphynx
Sphynx/Mix
Tabby
Tiger
Tonkinese
Tonkinese/Mix
Torbie
Tortoiseshell
Toyger
Turkish Angora
Turkish Angora/Mix
Turkish Van
Turkish Van/Mix
Tuxedo
Unknown
York Chocolate
128
Other Pet Species
129
Medical Event
130
Has this pet had their rabies vaccination?
Yes (Rabies)
No (Rabies)
131
Vaccine Name
132
Date of Vaccination
Please use XX/XX/XXXX format.
133
Where did they receive this vaccine?
134
What vet office does your pet use?
Put N/A if they do not have one.
135
Please list your pet's current medications, illnesses, injuries, or ailments.
136
Has your pet ever bitten anyone?* This field is required.
Yes
No
137
Please give us a brief description of the bite incident.
138
Add a photo of your pet
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
139
If your animals are not spayed or neutered, are you willing to have them altered within 3 months of starting this program?* This field is required.
Yes
No
140
If your animals do not have their rabies vaccination, are you willing to get them vaccinated within 3 months of starting this program?* This field is required.
Yes
No
141
Please provide additional details on how we can assist you.
142
Pet Pantry Waiver* This field is required.(Please be sure to read all the contents)
143
Important Details

By clicking "Submit" you understand and agree to the following:

I understand that any pet(s) entering the Stronger Together program will be spayed/neutered if they are not already fixed.

I understand that I must release my pet(s) to CHS to participate in this program. I understand that I will be able to adopt my pet(s) back at the end of the boarding period. The adoption fee for my pets will be waived, but boarding fees may apply. Applicable boarding fees will be discussed prior to pets entering the program.

Communication is a vital part of the Stronger Together program. I understand that I, or a third-party representative, will need to check in with CHS once every two weeks while my pet(s) is in this program.

This application does not guarantee the placement of your pet(s) in this program. A CHS representative will reach out to the applicant within 2 business days.
144
If you have any issues or concerns with the information you've had to enter on this form please send us an email at outreach@chesapeakehumane.org.
145
How did you hear about the Chesapeake Humane Society?
146
Please verify that you are human* This field is required.
147
Case Contact Plan:
148
Plan for continued assistance:
149
Org Notes 1
Medical: 
Exams: 
S/N: 
Vaccines: 
Microchip: 
Bloodwork: 
Flea Prevention: 
HW Prevention: 
Dewormer: 
Snap test: 
X-ray: 
Other:
Huge
Large
Normal
Small
Ok
Ok
150
Org Notes 2
Medical:
Exams:
S/N:
Vaccines:
Microchip:
Bloodwork:
Flea Prevention:
HW Prevention:
Dewormer:
Snap test:
X-ray:
Other:
Huge
Large
Normal
Small
Ok
Ok
151
Org Notes 3
Medical:
Exams:
S/N:
Vaccines:
Microchip:
Bloodwork:
Flea Prevention:
HW Prevention:
Dewormer:
Snap test:
X-ray:
Other:
Huge
Large
Normal
Small
Ok
Ok
152
Org Notes 4
Medical:
Exams:
S/N:
Vaccines:
Microchip:
Bloodwork:
Flea Prevention:
HW Prevention:
Dewormer:
Snap test:
X-ray:
Other:
Huge
Large
Normal
Small
Ok
Ok
153
Org Notes 5
Medical:
Exams:
S/N:
Vaccines:
Microchip:
Bloodwork:
Flea Prevention:
HW Prevention:
Dewormer:
Snap test:
X-ray:
Other:
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: