Pre - Need Owner Statement

Save Our Setters, Inc. Pre-Need Owner Representation

Please submit one (1) form per dog. A copy of this form should be provided to your personal representative (executor or administrator) appointed to manage your affairs. It will be incumbent upon your personal representative to notify Save Our Setters that the dog(s) need to come into rescue.
Dog's Name*
Sex*

MaleFemale
Spayed/Neutered*

YesNo
Approximate Date of Birth (Month/Year)
Where did you get the dog?*
Where did you get the dog (Breeder name, Rescue name, Website name, etc.)? If other, please explain.
Breeder Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Breeder Phone Number
Please enter a valid phone number.
If found, please list how, where and when.
Are registration papers available?

YesNo
Will you be providing a copy of this document to your veterinarian? PLEASE NOTE: Veterinarians will not provide any records unless they have a release from you on file.

YesNo
Veterinarian's Name
Veterinarian address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Veterinarian Phone Number
Please enter a valid phone number.
If you provide your own vaccinations and/or preventative medications, please keep an updated copy of those records attached to this form. This includes those vaccinations/preventatives provided by any source other than your vet.
Are there any recurring health problems of which Save Our Setters should be aware?
What Brand and type of dog food do you feed the dog?*
For example: Purina Pro Plan Chicken and Rice Dry
How many times a day?
What times?
How much each serving?
Where does the dog sleep?
Where do you keep the dog during the day?
Do you have a fenced yard?*

YesNo
If so, what is the fence height and material?
How much exercise does the dog normally get on an average day?
What commands does he/she know?
Do you believe the dog has ever been abused? If yes, please explain the dog's behaviors that led to that belief.
Has the dog ever growled at anyone?*

YesNo
If yes, what were the circumstances?
Has the dog ever bitten a person?*

YesNo
How many times has your dog bitten a person?
For each human bite incident, please provide the date(s), where the bite occurred, the triggers that led to the bite, the injuries and the severity of the bite.
Has the dog ever bitten another domestic animal?*

YesNo
How many times?
For each animal bite incident, please provide the date(s), where the bite occurred, the triggers that led to the bite, the injuries and the severity of the bite.
Did the dog bite the other animal defending itself, or was the dog the aggressor? Select all that apply.

Defending itselfDog attacked, unprovokedDog attacked, provokedOther
Select all that apply.

DogCatRabbitChickenOther

Does your dog:

	Yes	No	I don't know
like to ride in cars
let you take toys away
like to swim
bark excessively
chase cars
jump fences
chew excessively
urinate when scared
growl at strangers
come when called
like to dig

Is your dog:

	Yes	No	I don't know
afraid of storms
used to being groomed
obedience trained
house trained
crate trained
aggressive with food
used to being walked (leash trained)
Okay being left alone

How did the dog react when around these types of individuals and animals?

	Very well	Good but nervous	It was not a good experience	Never been around them
Children 0-5 yrs
Children 6-12 yrs
Teenagers
Adult Males
Adult Females
Elderly Persons
Individuals using mobility aids (Walkers, Canes, Wheelchairs)
Other Dogs
Cats
Birds

List any other information that might be helpful for the future foster home and/or adopters.
Have you set up a Trust or a Fund to support this dog should the need arise?

YesNo
If yes, please provide name and contact information for those who would have knowledge in this regard.
I/WE CERTIFY THAT I/WE OWN THE ABOVE DOG AND THAT THE STATEMENTS ABOVE ARE TRUE AND ACCURATE. SHOULD THERE BE SIGNIFICANT CHANGES TO THE INFORMATION PROVIDED ON THIS FORM, PLEASE COMPLETE A NEW FORM WITH THE MOST CURRENT INFORMATION AVAILABLE.

THIS PRE-NEED FORM IS FOR INFORMATIONAL USE ONLY.

******************************
Owner's Name*
Owner's signature*

Clear
Date of Owner's Signature*

MonthDayYear
Date
Owner's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner's Phone Number*
Please enter a valid phone number.
Owner's Email*
example@example.com
Co-Owner's name
Co-Owner's Signature (if applicable)

Clear
Date of Co-Owner's Signature (if applicable)

MonthDayYear
Date
Save Our Setter Contact Information

intake@saveoursetters.org

Save Our Setters, Inc.

PO Box 304

Cottontown, TN 37048-0304
Should be Empty:

Save Our Setters, Inc. Pre-Need Owner Representation