Dog Assistance Request

Dog Assistance Form

If you plan to surrender multiple dogs, please use a separate submission form for each dog.
REQUESTER INFORMATION
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Best Time to Call
How did you find us?

Internet searchSocial mediaRecommendedOther
Where did you get your dog?

StrayShelterFriendBreederOther
If you got your dog from a breeder, what was the breeder name?
Breeder Email (if known)
example@example.com
Breeder Phone Number (if known)
Please enter a valid phone number.
Do you have documentation indicating the dog is a purebred Havanese?

YesNo
Details on documentation.
DOG GENERAL INFORMATION
Dog's Name
When did you get your dog?
Month and Year
Dog's weight
Dog's age
Select the option that best matches your dog:

Dog is spayedDog is neuteredDog is intact
Where is the dog located? (City and State)

Street Address

Street Address Line 2

CityState

Zip Code
BEHAVIOR QUESTIONS
I certify the dog has never bitten a human or another dog and drawn blood. I certify that the dog has never aggressively bitten a human or other pet.

CertifyCan Not Certify
Is the dog good with cats?

YesNoUnsure
Describe in detail any information regarding the dog's behavior around cats.
What is your dog's reaction to other dogs?

FriendlyFearfulDepends on size of other dogReacts when leashedBarksGrowls and/or lungesMay attackOther
Describe in detail any information regarding the dog's reaction to other dogs.
What is your dog's reaction to children under the age of 12?

FriendlyPlayfulFearfulMay Snap
Describe in detail any information regarding the dog's reaction to children under the age of 12.
What is your dog's reaction to children over the age of 12?

FriendlyPlayfulFearfulMay snap
Describe in detail any information regarding the dog's reaction to children over the age of 12.
What is your dog's reaction to grooming?

EnjoysDislkesNeeds an assistantRequires professional handlingOther
Describe in detail any information regarding the dog's reaction to grooming.
What is your dog's reaction to visiting the vet?

Generally comfortableFearfulRequires muzzleOther
Describe in detail any information regarding the dog's reaction to visiting the vet.
Does this dog have special needs?
REASON FOR THE REQUEST
Explain the circumstances prompting you to request assistance for the dog, or why you desire to surrender this dog to HRI.
Upload 2 photos of your dog: 1 from the front and 1 standing from the side.

Cancelof
Math Challenge
Should be Empty:

Dog Assistance Form

REQUESTER INFORMATION

DOG GENERAL INFORMATION

BEHAVIOR QUESTIONS

REASON FOR THE REQUEST