Animal History Form

Animal History Form - DOG
Date

MonthDayYear
Date
The Animal Protection Society - Friday Harbor's policy for owner relinquished dogs: APS-FH accepts pre- approved owned animals from San Juan County residents. In relinquishing your animal to APS-FH you must understand and agree to the following:
- You are the legal owner of the animal you are relinquishing.
- You are at least 18 years of age.
- Admissions to APS-FH will be assessed on physical and behavioral health of the animal to determine adoptability as well as space available at the shelter. APS-FH reserves the right to deny a relinquishment to the shelter for any reason.
- YOU WILL ANSWER THE QUESTIONS ACCURATELY AND THOROUGHLY TO PROVIDE THE BEST CARE FOR THE ANIMAL AND FOR THE SAFETY OF THE SHELTER STAFF/VOLUNTEERS.
Owner Information
Name
If owner is deceased, guardian name
Address
Phone Number
Alt Number
Email Address
example@example.com
General Information - Dog
Name
Sex

MaleFemale
Spayed/Neutered

YesNo
Age/DOB
Color(s)
Pattern
Breed
Microchipped

YesNo
Microchip Brand
Microchip #
Does your dog have any allergies, health problems, or injuries? If yes, please describe.
Does your dog have any special needs? (EX. blind, deaf, injured, sick, seizures, pregnant, bottle fed, other)
Is your dog on any medications? If yes, please describe.
Are you the dog's original owner?

YesNo
If you are not the original owner, please give us a much previous history as possible.
How long have you had the dog?
Where did you acquire the dog?
Are you obligated to return the dog to the person/organization you received them from?

YesNo
Veterinary clinic that your dog frequented
Phone Number
Date of last vet visit

MonthDayYear
Date
Name of the person that the records are under
What issues are you having with keeping this dog? Please give as much detail as possible. EX. change in family, moving, housing, behavior, cannot afford, pet illness, health of owner, allergies, neglect
How can we help you with the issues that you are having with your dog?
If we could help you re-home your pet, would you consider housing your dog until a new home is found allowing them to stay in a familiar environment with their family, while they wait for their new family?

YesNo
If yes, what is the maximum time you can house your dog during this search?
Personality Profile
What is your dog's personality like? (Check all that apply):

Likes to cuddleCouch potatoActiveHyperAffectionateDestructiveShyLoves to playIndependentFearfulFriendlyNoisy
Where does your dog sleep?
What does your dog eat? (Check all that apply):

Canned foodDry foodRaw dietPrescription food
Brand
Home Environment and Behavior
Describe your pet's behavior around children (Check all that apply):

Never been around childrenUnpredictableRoughGentleAvoids childrenFriendly/playfulNervous/scaredIgnores
What human family members has your dog lived with? (Check all that apply):

Adult menAdult womenSenior citizensTeenagersChildren
Please check all the animals your dog has lived with

Male catFemale catMale dogFemale dogBirdsRabbits/Guinea pigsReptilesLivestock
Describe your dog's behavior around other dogs (Check all that apply):

Never been around other dogsScaredFriendly/playfulAffectionateIgnoresBossyAggressiveLoves to playSubmissiveRoughResource guardsProtective of home
Describe your dog's behavior around strangers (Check all that apply):

Never been around new peopleScaredFriendly/playfulAffectionateIgnoresBossyAggressiveLoves to playSubmissive
Describe your dog's behavior around cats (Check all that apply):

Never been around catsScaredFriendly/playfulAffectionateIgnoresBossyAggressiveLoves to playSubmissive
Where was the dog kept when no human members of your family were home (Check all that apply):

Free run of the homeCratedYardConfined to one roomTied outside on chain/runner
Does your dog have accidents in the house often?

YesNoSometimes
If yes, how long is your dog left alone?
What method of housetraining does your dog know? (Check all that apply):

Paper trained/potty padsDoggy doorCrate trainedBells on/by the door
Is your dog crate trained?

YesNo
If yes, how long each day?
Has your dog ever bitten a person?

YesNo
If yes, what date was the incident?

MonthDayYear
Date
Please explain the circumstances:
Has your dog ever bitten another animal and caused damage?

YesNo
If yes, what date was the incident?

MonthDayYear
Date
Please explain the circumstances:
Is your dog frightened of anything? (Check all that apply):

MenWomenTeenagersChildrenStrangersFireworksCarsThunder/lightningBikes/skateboardsYelling/loud noisesVacuumVet/groomer
Has your dog had any behavior training?

YesNo
If yes, what type of training has your dog had? (Check all that apply):

Puppy classHome trainingObedience classesPrivate training
Does your dog have any of the following behavioral issues? (Check all that apply):

Resource guardingPotty accidents/marking indoorsEscaping outsideJumping up on peopleJumping on countersDestructive chewingHuman aggressionAnimal aggressionExcessive barkingRunning away
What type of exercise does your dog receive on a regular basis? (Check all that apply):

Leash walksHikingRunning/joggingPlays fetchDog parkPlay in yardPlays with other dogsNo exercise
What area of your home did your dog have access to? (Check all that apply):

Outdoors onlyIndoors at nightBasementOutdoors in warm weatherIndoors onlyScreened in porchGarageIndoors in coldIndoors with access to outside
DONATION

We ask for a donation of $100 when surrendering your dog. Your donation assists in providing food, shelter, and medical care for your animal. Any additional donation is greatly appreciated.

I understand that APS-FH is a 'No-Kill' Shelter for "adoptable" animals. If this animal is determined unadoptable by the behavioral or medical staff and no other alternative can be found, there is a possibility the animal may be humanely euthanized without the original owner notification.

While at APS-FH, all animals receive necessary veterinary care, nourishment, and exercise. There is no set time limit for how long an animal can remain in our adoption program. As long as an animal maintains general good health and sound temperament, we will keep the dog until they are adopted. Unfortunately, there are times when circumstances present themselves (e.g. out of space, sensitive situation) and animals may have to be transferred to another 'no-kill' shelter, however, our goal is to find adopters for all of our

I CONFIRM THAT I AM THE RIGHTFUL OWNER OF THIS DOG AND I HEREBY RELEASE ALL RIGHTS AND GIVE FULL CUSTODY OF THE ANIMAL DESCRIBED ABOVE TO THE ANIMAL PROTECTION SOCIETY FRIDAY HARBOR.
TO THE BEST OF MY KNOWLEDGE, THE ANIMAL HAS / HAS NOT BITTEN ANY PERSON OR ANIMAL IN THE LAST 10 DAYS.

HasHas not
Print Name
Date

MonthDayYear
Date
Signature

Clear
Animal Protection Society Friday Harbor

938 Cattle Point Rd. Friday Harbor, WA 98250
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Animal History Form - DOG

Owner Information

General Information - Dog

Personality Profile

Home Environment and Behavior