Intake Request Questionnaire

Intake Request Questionnaire

Please fill out this questionnaire if you would like us to consider taking your dog into Doberman Rescue of Atlanta.
Dog Owner's Name*

First NameLast Name
Dog Owner's Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Dog's Name*
Dog's Gender*

MaleFemale
Dog's Breed*
Doberman, Doberman Mix, Rottweiler, etc.
Dog's Age
Color*

BlackRedFawnBlueAlbinoNo Sure
Ears*

CroppedNatural (not cropped)Not sure
Tail

DockedNatural (not docked)Not Sure
Which vet clinic has treated this dog?
Name of vet clinic
Vet Clinic Phone Number
Please enter a valid phone number.
Vet Clinic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you owned this dog?
Where did you acquire this dog ?
(breeder, shelter, rescue, etc.)
Why do you want to surrender this dog?*
Medical Information
Has this dog been spayed or neutered?*

YesNoI don't know
Do you know when this dog was last vaccinated?*

YesNo
Date of last vaccinations (approximate is ok)
Approximate date dog was last vaccinated
Do you know when this dog last had heartworm prevention (like Heartgard)?*

YesNo
When did this dog last have heartworm prevention?
Any known medical issues or allergies?
Dog Behavior/Temperament
Is this dog comfortable with...(only check a box if you know the dog does not have issues with that selection)

Male DogsFemale DogsCatsChildrenMenWomenStrangersRiding in the Car
Does this dog live mostly indoors or mostly outdoors?

Mostly indoorsMostly outdoorsAbout half and halfI don't know
Is this dog housebroken?

YesNoPartiallyDon't know
Is this dog crate trained?*

YesNoNot sure
Is this dog leash trained?*

YesNoNot sure
Does this dog....*

Jump fencesDigChewGuard foodGuard toysNone of the above
Does this dog bark...*

NeverOccasionallyExcessivelyAt strangers and noiseNot Sure
Has this dog ever bitten a human?*

YesNoUnknown
Describe the situation where the dog bit a person.
Have you ever received any citations from any governmental entity or been sued because of this dog?*

YesNo
Describe the situation which led to you being sued or issued a citation.
Has this dog ever attacked another dog or gotten into a fight with another dog, even if it was one of your own dogs?*

YesNoUnknown
Describe the attack or dog fight.
Does this dog have separation anxiety?*

YesNoUnknown
Describe the separation anxiety.
Does this dog allow you to take away bones, toys and food?*

YesNoUnknown
Does this dog try to keep other dogs or people away from his/her owner?*

YesNoUnknown
List any commands this dog knows.
Does your dog have any specific preferences for interaction?
(e.g., likes belly rubs, dislikes being picked up)
Has your dog undergone any training, and if so, what type?
Does your dog exhibit any fears or phobias?
(e.g., thunderstorms, fireworks)
Does your dog show any signs of aggression?
(towards people, other dogs, or specific situations)
How does your dog behave in new environments?
Does your dog have any special needs or preferences you'd like to share?
(e.g., dietary restrictions, favorite toys)
Is there anything else you'd like to add about your dog's behavior, personality, or any specific concerns?
Upload a photo of your dog (optional)
Date

MonthDayYear
Should be Empty:

Intake Request Questionnaire

Medical Information

Dog Behavior/Temperament